Hospitals in New Jersey and Ohio and in a few cities across the United States are giving away cardboard boxes to parents of newborns as part of an effort to decrease accidental infant deaths by providing an uncluttered place for the child to sleep.
This story about the initiative does not include any research results about these boxes, but implies that they are making babies safer without evidence. Parents may learn more about infant sleep safety when they watch some videos as part of getting their box. We wish the story had directly asked the for-profit company how it can afford to give these boxes away and how it makes money. Are the boxes a loss leader for other products the company hopes to sell? Is the information collected by Baby Box sold to companies who want to market to these parents? Readers want to know how this works and whether the boxes really are “free” or come with hidden costs. An outside expert would have been helpful here, too, perhaps providing insight into what constitutes safe sleeping and how the boxes might be an aid, or whether other factors might be at play.
In Finland, the gift of a box to parents is credited with helping decrease infant sleeping deaths, but it could also be that national health insurance and better care for pregnant women and new mothers also contributed.
Sudden unexplained infant death, SUID, occurred about 3,700 times in the United States during 2015, according to the Centers for Disease Control and Prevention (CDC). SUID refers to the sudden death of an infant for no obvious cause. Within that number are both children whose cause of death is never explained and children who may have smothered in bedclothes and whose cause of death is explained. This heartbreaking loss of children is the number one cause of death in that age group.
What this story claims is that the cardboard boxes distributed for free from a for-profit company are proven to reduce risk of SUID. But the story offers no proof. A closer look reveals that parent education may be the key — not the box — and parents benefit from understanding how to keep their child’s sleeping place uncluttered. We wish the story had given a reference to any research and quoted more experts.
An article on baby boxes by NBC News offers a more complete story. It still does not offer any evidence that the baby boxes given out in the United States are having a risk-reduction impact, but it explains why European countries give out boxes and that their rates of death are lower. It also expands on alternative recommendations for providing a safer sleeping environment for newborns.
The story does say that these boxes are being distributed for free, but by a for-profit company that requires parents to “register” at a website in order to receive one.
We think the collection of information on new parents may benefit the for-profit company. The story would have been stronger if it faced that issue squarely. See more on this under the funding and conflicts of interest criteria section below.
The story does not quantify any of the benefits. It does not tell us how much risk of sudden infant death is decreased by the child sleeping in these particular boxes. In the excerpt below, a pediatrician is quoted saying the boxes “provide a clutter-free sleep space” and that has been shown to reduce accidental deaths. But just to clarify – it would seem you don’t have to use one of these boxes in order to provide a “clutter-free sleep space?” Can’t a family create a clutter free space in their own cardboard or an empty clutter-free crib?
The quoted pediatrician does not give us any research source for the proof of a benefit.
“The idea for baby boxes started in Finland in the 1930s, and is tied to a sharp drop in sudden infant deaths, according to Dr. Kathryn McCans, a pediatrician who chairs New Jersey’s Child Fatality and Near Fatality Review Board. The boxes provide a clutter-free sleep space that has been shown to reduce accidental and unexpected deaths, she said.”
Can’t parents provide a clutter-free sleep space for their infants on their own? Yes, but it doesn’t mean they will. The convenience and no cost of the box to the parents might be sufficient motivation to use it and the parents don’t need to do anything to make it safe — it already is. This in essence makes the right thing to do into the easy thing to do — a key tenet of patient safety. However, the concern that there simply are no numbers showing a benefit is a real one.
The story does not include any mention of harms. Just because something doesn’t seem harmful, we would still like a story to note “There are no known harms” because that means they’ve given it some thought.
The story has no foundation of evidence. We are not provided with any research studies, even from Finland, where the historic practice of baby boxes originated.
After a real effort to find them, we could find no studies other than the trend data from Finland, so the article would be hard-pressed to quote any. The story should have noted the lack of research. This is an instance where a logic model is being used: the box mitigates some of the known causes of SUID and SUID rates go down. Therefore, the boxes are likely responsible.
But just because something sounds logical, doesn’t make it true. Parent education could be the key factor as noted above. Other causative factors for the decreased rate of SUID with the boxes could be the firm mattress and no bumper pads in the box. There is good evidence for both of these as important risk factors for SUID.
The story tells readers that the Baby Box Co. is a “for-profit” company. But they don’t give us any details about the company’s relationship with the pediatrician, Kathryn McCans, who is the only physician quoted in the story.
Does Dr. McCans receive any funding or payment from The Baby Box Company? We can’t tell from the story. At the company’s own website, she is listed as one of “our experts” on this page.
She may have donated her time, but that isn’t made clear. At the very least, it should have been clarified that that McCans has a relationship with the company and is not totally independent.
We think the headline and most of the story makes the boxes seem very important.
This is the only sentence that hints there are alternatives. “The boxes aren’t the only option for safe sleeping, of course, but health officials say they’re a useful part of a broader safe-sleep education program.” (Italics by reviewers.)
If the boxes are just part of a broader education, then perhaps it isn’t “ditching the crib” as the headline says that leads to safer infant sleep but parent training that advises a firm mattress, bumper-free cribs and absence of clutter that are keys to a safer sleeping environment.
The boxes are given away, but parents have to “register” through babyboxuniversity.com.
They must “watch a handful of videos on sleep safety and pass a quiz. Parents can then take their digital or printed-out certificates to a participating hospital for their boxes. The boxes can also be sent in the mail, if a nearby hospital is not designated as a distribution center.”
We are left unsure whether any parent can get a box from the company without registering or can a parent watch the educational material without registering and giving away his or her identity?
The story does not claim boxes are novel everywhere, but suggests they are a growing initiative in the United States.
This story doesn’t appear to be based solely on a news release.
Systematic, Criteria-Driven
Monday at #ADA2021, an infectious disease epidemiologist, a journalist, and a researcher shared perspectives on communication of risk in the era of COVID-19: http://ow.ly/ROfR30rMeE7 @AstleyCM @garyschwitzer @berthahidalgo @ADA_DiabetesPro
Shoutouts to @susan_bewley @drkevinknopf @MichaelBaum11 in this call for more than fawning coverage from press releases for these kinds of stories.
Also, linked history inside goes back 5 years just on Grail apparently trying to become Holy Grail. https://twitter.com/garyschwitzer/status/1408849696416841731
Comments (1)
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Gary Schwitzer
March 16, 2017 at 11:14 amA reader sent us this article from The Globe and Mail: “North American ‘baby box’ initiatives are a far cry from Finland’s universal program.”
http://www.theglobeandmail.com/life/health-and-fitness/health/canadas-baby-boxes-wont-bring-pregnant-women-into-health-care-system/article30105424/
Gary Schwitzer, Publisher
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