School of Public Health

Safer Sleep: An Overview of Bed-Sharing Alternatives

July 2018
Author: Malka Main

Despite widespread advice against bed-sharing1, parents continue to sleep next to their babies … on beds, in armchairs, and on sofas.2 These sleep practices are associated with 60% of sudden unexpected infant death (SUID) cases.Acknowledging that parents don’t always follow safe sleep recommendations, the American Academy of Pediatrics (AAP) Task Force added bed-sharing modifications to their 2016 update and encouraged practitioners to have open conversations with caregivers about risk reduction.3

Programs such as Cribs for Kids and the now-retired Bedtime Basics for Babies addressed the financial barrier to safe sleep practices by offering parents approved cribs at no cost. But lack of money isn’t the only barrier. Sometimes it’s logistics (perhaps there is no place to put a crib or play yard) and sometimes it's a lack of understanding (for instance, that SIDS has no known cause undermines some parents’ acceptance of safe sleep recommendations ).4 But bed-sharing also persists because it is so often part of a larger family or cultural tradition.5

Several public health programs have taken an individualized approach to safe sleep intervention. These programs offer alternative sleep surfaces (those not recommended by AAP, but identified as safer than direct bed-sharing) with safe sleep education that is often tailored through conversation to reflect a family’s social and cultural context. This approach is consistent with evidence that shows personalized interventions can be more effective than the one-size-fits all approaches.5

Below are a few examples of alternative infant sleep surfaces discussed within the public health literature, links to some of the available evidence of their relative safety, and ways to discuss their use with parents to minimize risk of SUID.

Note: According to the AAP, the safest infant sleep space is a crib, bassinet, portable crib, or play yard that conforms to the Consumer Product Safety Commission standards. The products highlighted in this article have not undergone the same rigorous safety investigations but are identified by some public health officials as safer alternatives to beds or other household furniture. No matter the sleep surface, risk is always reduced when caregivers place infants to sleep on their backs, alone, with no loose bedding or soft objects.1


wahakura basket, SIDS prevention, safe sleep
SOURCE: A cradleboard made in a class hosted by Native American Women's Dialogue on Infant Mortality.

What is a cradleboard?

A cradleboard is a traditional American Indian and Native Alaska (AI/AN) baby carrier. While styles vary across tribes, cradleboards typically consist of a flat rounded wooden board with a protective roller bar and fabric sides that snugly lace-in a swaddled infant (placed on its back). The cradleboard can be carried in the arms, worn on the back, propped up like a baby chair, or laid flat on a sturdy surface. Cradleboards are made by hand, often by a family member or close friend who thinks prayerfully and intentionally of the health of baby who will use it.

Implementation in Public Health

Public health officials encourage special focus on safe sleep promotion for AI/AN babies whose SUID rates remain the highest of all races and ethnicities in the United States. The National Institute for Children’s Health Quality (NICHQ) and National Institutes of Health and Human Development (NICHD) both suggest cradleboards as a culturally-appropriate infant sleep surface. 6

While there is currently no large-scale effort to promote cradleboard use as a safe sleep intervention, several community-level efforts across the country offer cradleboard classes for AI/AN families. Cradleboard classes provide safe sleep education, a safer sleep product, and social support for expectant families. The classes and support also help Native mothers connect with their culture, which evidence suggests may be protective against infant mortality.7

In Washington state, the Native American Women’s Dialog on Infant Mortality (NAWDIM),  offers cradleboard classes in and around Seattle, when they are able to secure funding. NAWDIM is a collective of community members, social service and medical providers, and allies. Cradleboard class attendees spend the day constructing cradleboards from preassembled components, building community with other families, and learning about nutrition, breastfeeding, and the best ways to keep their baby safe during sleep.

Evidence and Safety

There are no known studies of cradleboard and sleep safety. However, NICHD’s Healthy Native Babies Project workbook considers the cradleboard “one of the safest alternative sleep surfaces.”8

Risk Reduction with the Cradleboard8

  • Caregivers should be sure the baby does not overheat in the cradleboard as overheating is a risk factor for SIDS. Depending on the ambient temperature, a light blanket may be sufficient.


baby box, SIDS prevention, safe sleep

Temima Schulgasser slept in a baby box until she was 4 months old.SOURCE: Channa Schulgasser.

What is a baby box?

A baby box is a cardboard box lined with a mattress pad, and typically comes filled with diapers, lotion, diaper cream, milk storage bags, and baby wipes. The box is intended to be an infant sleep surface. The concept originated in Finland before World War II and has been widely adopted in the U.S. and Europe over the past few years.

Implementation in Public Health

Hospitals and public health agencies across the country partner with baby box manufacturers to give boxes to parents who agree to receive safe sleep messaging (either through in-person appointments or a series of educational videos). State maternal and child public health programs that distribute baby boxes to new parents include Alabama, California, New Jersey, Ohio, and Wisconsin.9

Misconceptions about Baby Boxes

Media coverage of the baby box often implies a strong association between Finland’s baby box program and its low infant mortality rate, but experts say this is misleading. The program was introduced in the 1930s, at a time just shortly before all industrialized countries experienced a decrease in infant mortality due to better sanitation, nutrition, obstetric care, and advanced medical technology. 10

While Finland does have one of the lowest rates of infant mortality in the world, this is more likely associated with the country’s comprehensive social support for parents including universal health care, home visits from healthcare workers, and generous parental leave.11

Evidence and Safety

Researchers at Temple University studied a baby box program in Philadelphia that provides mothers with a box and face-to-face safe sleep counseling. The results: the baby box program reduced the rates of bed-sharing by 25% in the first 8 days of life and by 50% for exclusively breastfed infants.12

There are no known studies on the safety of the baby box itself. Some manufacturers advertise that the baby box has been successfully tested against international safety standards for bassinets, however, the baby box does not meet the definition of a bassinet and therefore cannot conform to these safety standards.13 The Consumer Product Safety Commission has convened a task force to determine national standards for the baby box. Public health experts recommend research to address the following concerns:14, 15, 16

  • the interaction of cardboard with an infant’s exhaled carbon dioxide (Inhaling carbon dioxide – also called rebreathing  is a risk factor for SIDS)
  • the impact of spit-up or leaking diapers on the structure of the box over time
  • an action plan for transitioning out of the box to a safe sleep surface – the average U.S.-born infant will outgrow the box around 2-4 months (a peak risk period for SUID)

Risk Reduction with the Baby Box 1,9

  • Place it on a dry, sturdy surface, if it is on the floor ensure it is in a space where nothing can fall into it, no one will trip over it, no family pets can get into it, and there are no pest control issues
  • Do not use soft objects or loose bedding in the box


cradleboard, SIDS prevention, safe sleep
SOURCE: Dr. David Tipene Leach.

The wahakura basket is a product developed by the indigenous Maori community in New Zealand. Like the American Indian/Alaskan Native population in the U.S., Maori infants in New Zealand are at disproportionate risk for SUID compared to their White counterparts. The wahakura basket is the only known alternative sleep surface that has undergone randomized controlled trials to assess safety and use.

What is the Wahakura Basket?

The wahakura is a woven, flat-bottomed basket, (typically about 14 x 28 inches) that can be placed on any sturdy surface.

Implementation in Public Health

New Zealand’s National SUDI Prevention Programme, the Hapai Te Hauora (a Maori health organization), and regional health agencies give these baskets  to Maori parents along with an evidence-based set of infant safe sleep guidelines and an understanding that the parents will pass on safe sleep information to family and friends. Some of the programs host wahakura weaving classes to teach pregnant mothers safe sleep through conversation and community. Mothers who attend have a responsibility to pass on the safe sleep strategies they learn during the class to their friends.17

Evidence and Safety

Recent randomized trials found that the wahakura basket itself is as safe as the recommended bassinet18 and that parents who used the basket instead of the bassinet were no more likely to bed-share, cover the infant’s head, or lay them to sleep on their sides or stomachs. Researchers did find one significant difference:  women who used the wahakura basket were twice as likely to continue breastfeeding as those who used the bassinet.19

Risk Reduction with the Wahakura20

  • Always lay baby down to sleep on the back
  • Don’t put pillows, blankets, or soft toys inside the basket
  • Make sure there are no gaps between the baby’s mattress and the side of the basket
  • Don’t bring the basket into the bed of an adult who is exhausted or intoxicated


New Zealand’s national safer sleep program could be a model for public health efforts in the United States to address racial and ethnic disparities in sleep-related infant deaths through risk reduction.

In New Zealand, the safer sleep program was associated with a 29% drop in infant mortality between the years 2002 and 2015. The decrease was most dramatic among Maori babies and in the districts where public health distributed the most wahakura baskets and pepipods (a plastic version of the basket).17, 21

Experts attribute the success of the program to the government’s collaboration with Maori leadership on culturally appropriate practices that promote safer bed-sharing versus no bed-sharing. The multi-method approach of the collaborative intervention included SUID education to help professionals discuss safe sleep with families, messaging that shifts the focus away from “confusing terms associated with sudden infant deaths” to the prevention of accidental suffocation, the distribution of alternative safe sleep surfaces, such as the wahakura basket, and personalized, culturally-appropriate parent education.17, 21




  1. Task Force on Sudden Infant Death Syndrome. SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment. AAP. 2016; 138(5).
  2. Batra EK, Teti DM, Schaefer EW, Neumann BA, Meek EA, Paul IM. Nocturnal Video Assessment of Infant Sleep Environments. AAP. 2016;138(3).
  3. Schnitzer PG, Covington TM, Dykstra HK. Sudden Unexpected Infant Deaths: Sleep Environment and Circumstances. AM J Public Health. 2012;102(6):1204-1212.
  4. Moon RY, Oden RP, Joyner BL, Ajao TI. Qualitative analysis of beliefs and perceptions about sudden infant death syndrome (SIDS) among African-American mothers: Implications for safe sleep recommendations. J Pediatr. 2010;157(1):92–97.
  5. Moon RY, Hauck FR, Colson ER. Safe Infant Sleep Interventions: What is the Evidence for Successful Behavior Change? Curr Pediatr Rev. 2016;12(1):67-75.
  6. National Institute of Children’s Health Quality. NICHQ Drivers. 2017.
  7. Native Generations: A Campaign Addressing Infant Mortality Among American Indians and Alaska Natives in Urban Areas 
  8. National Institute of Child Health and Human Development and the Native American Management Services. Healthy Native Babies Project. June 2010. National Institutes of Health.
  9. Baby Box Company.
  10. Selk S, ScD. The Baby Box: An Opportunity, Not A Magic Bullet. NICHQ. Updated 2018. Accessed
  11. Moon RY. Baby Boxes. University of Virginia School of Medicine.
  12. Heere M, Moughan B, Alfonsi J, Rodriguez J, Aronoff S. Think inside the box: acceptance of Universal baby box distribution by mothers discharged from an urban university maternity service. Paper presented at: Pediatric Academic Society Meeting; May 6, 2017; San Francisco, CA.
  13. CPSC Statement on Cardboard Baby Boxes. United States Consumer Product Safety Commission.
  14. Weil A. ARe baby Boxes Safe? Andrew Weil MD website. l April 14, 2017.
  15. United States Consumer Product Safety Commission. Commission Meeting: Public Hearing: Agenda and Priorities for FY 2018 and/or 2019.
  17. Cribs for Kids. Safety Standards of the Graco® Pack 'n Play® VS. A Cardboard Unit.
  18. Healthy Quality and Safety Commission New Zealand; Child and Youth Mortality Review Committee. Sudden unexpected death in infancy (SUDI): Special report. Published June 2017. 
  19. Physiological stability in an indigenous sleep device: a randomised controlled trial
  20. The wahakura: a qualitative study of the flax bassinet as a sleep location for New Zealand Māori infants
  21. Whanganui District Health Board. Wahakura Peip-Pod.
  22. Mitchell EA, Cowan S, Tipene-Leach D. The recent fall in postperinatal mortality in New Zealand and the Safe Sleep programme. Acta Pædiatrica. Received 12 April 2016. Revised 27 May 2016. Accepted 31 May 2016.