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The small Scandinavian country of Finland has one of the lowest rates of infant mortality in the world (two children under one year of age per 1000 live births). Many in the U.S., with three times that number of infant deaths, are suggesting a widespread program to use a tool Finland's parents have for preventing baby death, small cardboard boxes that help keep the little tikes safely in positions that lower sudden infant death syndrome (SIDS). Could this work here?

The answer is complicated. To a degree, differences in infant mortality stats reflect a measurement of apples vs. oranges. Some countries with lower infant mortality rates, for instance, do not count babies born weighing less than a pound, while typically such kids, often preemies, are factored into the statistics here, though they have much lower chances of survival than babies born later in the mother's pregnancy and with more normal weight and development.

In addition, in Finland there are two major aspects to their success in keeping infant mortality down: the little boxes plus assuring that most mothers-to-be have prenatal screening and medical care. In the U.S. it is true we do not greatly emphasize the special cardboard boxes that, when the children are placed in them, make it easier to avoid SIDS, but perhaps equally or more important, there is not always good access for expectant mothers to prenatal care.

baby boxes with twins kept safe - Maddie McGravey for NPR - 3-26-17 (npr.org)

Then there is the question of whether the little boxes really make a difference in preventing infant deaths. This is a bit controversial. Some pediatricians argue there has not been enough research into whether or not the little boxes are safe themselves, for example, whether or not their cardboard construction might increase the chances of infection after they have gotten wet or soiled. Proponents, though, suggest we ought not keep permitting thousands of infant deaths in this country while we pursue further testing and long-term studies. It is already known that intervention with the boxes in Finland, starting in 1938, helped reduce their nation's infant mortality from roughly one in ten to 2 per 1000. They also note that infections and even infant deaths can occasionally occur in more traditional cribs and bassinets as well, but their use is not avoided till more testing is done. Others point out the cost of the little boxes programs might be better used for more awareness projects, teaching parents the risks of putting their children to sleep on their stomachs, in cramped bed conditions where others might lie on them, with pillows or blankets that can suffocate the babies, or in spaces big enough to permit them to turn over after safely on their backs (the recommended posture for resting infants).

A cardboard box for an infant may seem like a crude, industrial, or impersonal way to treat a tiny baby. However, these boxes have comfortable little cushions, usually are pleasantly decorated, and also can be enhanced with names and pictures of the infant on the exterior. A few states and the District of Columbia have been trying out cardboard box programs for new babies, with generally very welcome results. Parents need not continue to use the boxes and might, for instance, substitute more substantial cribs and beds for the babies. Even in Finland, there has in recent years been a trend away from just using the free-to-parents boxes. Here as there, it appears that the more important factor is that parents receiving them also get educated on the best ways to keep their newborns as safe as possible. Along with the free boxes, if parents learn to avoid putting their babes in places where sleeping siblings or adults might accidentally lie on the infants, where the kids can turn over onto their tummies, or where they might get their faces under blankets or pillows, and if the infants' mothers can get fine prenatal medical or midwifery care, odds are the youngsters will have much better chances of surviving, and our infant mortality rates can be substantially reduced, annually tens of thousands of babies then perhaps being able to grow to maturity as a consequence. What's not to like?

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