Babies in boxes and the missing links on safe sleep: Human evolution and cultural revolution

Abstract

Concerns about bedsharing as a risk for sudden infant death syndrome and other forms of sleep-associated infant death have gained prominence as a public health issue. Cardboard "baby boxes" are increasingly promoted to prevent infant death through separate sleep, despite no proof of efficacy. However, baby boxes disrupt "breastsleeping" (breastfeeding with co-sleeping) and may undermine breastfeeding. Recommendations enforcing separate sleep are based on 20th century Euro-American social norms for solitary infant sleep and scheduled feedings via bottles of cow's milk-based formula, in contrast to breastsleeping, an evolutionary adaptation facilitating the survival of mammalian infants for millennia. Interventions that aim to prevent bedsharing, such as the cardboard baby box, fail to consider the implications of evolutionary biology or of ethnocentrism in sleep guidance. Moreover, the focus on bedsharing neglects more potent risks such as smoking, drugs, alcohol, formula feeding, and poverty. Distribution of baby boxes may divert resources and attention away from addressing these other risk factors and lead to a false sense of security wherein we overlook that sudden unexplained infant deaths also occur in solitary sleep environments. Recognizing breastsleeping as the evolutionary and cross-cultural norm entails re-evaluating our research and policy priorities, such as providing greater structural support for families, supporting breastfeeding and safe co-sleeping, investigating ways to safely minimize separation for formula-fed infants, and mitigating the potential harms of mother-infant separation when breastsleeping is disrupted. Resources would be better spent addressing such questions rather than on a feel-good solution such as the baby box.

“I See No Other Option:” Maternal Practices of Sleep-Training and Co-Sleeping as the Management of Vulnerability

“…Throughout the article, for clarity, I will refer to all of these practices under the heading of ' co-sleeping' in that they are all framed as alternatives to sleep-training, involve parental responsiveness to infants at night, and do not involved early independence training. of attachment also supports many of the claims made by co-sleeping advocates, who are able to cite studies indicating that infants left alone have elevated stress hormones even after they learn not to cry (Middlemiss, Granger, & Nathans 2012) and that over time, that this may impair brain development (Bartick et al 2017) as a result of 'toxic stress' (Shonkoff et al 2012). Sleep training practices are based on theories of behaviour modification (Hiscock & Fisher 2015).…”

“…The opportunity to stay home is most commonly provided by wage-earning partners. Practicing co-sleeping requires the maintenance of a breastfeeding relationship as it is considered unsafe for nonbreastfeeding parents to co-sleep (Bartick et al 2017). The continuation of breastfeeding itself can be understood as an economic privilege.…”

“…Unhelpfully, both sides engage different bodies of scientific literature (Hiscock & Fisher 2015). Co-sleeping practices are based on attachment theory and draw heavily on evolutionary biology and anthropological sources to determine human sleep behaviours (Bartick, Tomori, & Ball 2017;Büskens and maternal vulnerability. 3 Co-sleeping can refer to a range of practices and is often used ambiguously.…”

Bedsharing and Breastfeeding: The Academy of Breastfeeding Medicine Protocol #6, Revision 2019

“…102 One observational study has shown that, compared with mothers who room-shared without bedsharing, mothers who bedshared were more likely to report exclusive breastfeeding (adjusted odds ratio [OR]: 2.46; 95% confidence interval [CI]: 1.76-3.45) or partial breastfeeding (adjusted OR: 1.75; 95% CI: 1.33-2.31). 7,103 Therefore, advice to avoid bedsharing has the potential to undermine breastfeeding goals, 3,8,104,105 and may increase risk of sleeping in unsafe environments such as sofas. 106 Although mothers and infants can sleep apart and still breastfeed exclusively, doing so results in fewer sessions of breastfeeding per night: bedsharers have double or triple the number of breastfeeding sessions and total amount of breastfeeding time compared with solitary sleepers.…”

Concerns about the promotion of a cardboard baby box as a place for infants to sleep

“…Results from case-control studies internationally form the basis for infant sleep recommendations. We are, therefore, concerned that cardboard boxes are being promoted for infant sleep, as a safe alternative to the more traditional cots, bassinets, or Moses baskets, without any observational evidence in place 23. The cardboard baby box is based on a Finnish tradition of giving pregnant women a box full of free infant care items—including a mattress that fits into the bottom of the box as a makeshift infant sleeping environment—as an incentive to enter prenatal care early.…”