Resources, Conservation & Recycling 151 (2019) 104462

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Resources, Conservation & Recycling

journal homepage: www.elsevier.com/locate/resconrec

Full length article

Challenges and opportunities for reduction of single use plastics in T

healthcare: A case study of single use infant formula bottles in two Irish
maternity hospitals
⁎
Sonja Leissner, Yvonne Ryan-Fogarty
Faculty of Science and Engineering, University of Limerick, Limerick, V94 T9PX, Ireland

A R T I C LE I N FO A B S T R A C T

Keywords: The issue of plastic pollution is now recognised as a catastrophic global crisis. Single-use plastics have attracted
Single-use plastics much attention in terms of elimination and mitigation measures. The concept of circular economy aims to attain
Food packaging a state where waste no longer exists. Pathways to eliminate or adapt stages of the life cycle, long before the end-
Sustainable healthcare of-life phase, are necessary to address single-use plastics.
Waste management
This paper examines single-use food packaging plastic waste in Irish maternity hospital settings through a
Environmental management
case study of ready-to-use infant formula bottles. A quantitative and qualitative assessment of single-use plastics
Infant feeding
arising from infant feeding bottles is presented. Quantitative examination reveals a high variability in materials
used for bottles, teats and associated packaging, thus creating difficulties in standardising labelling and iden-
tifying appropriate waste treatment options. Quantitative calculations reveal the extent of plastic waste gen-
erated by this single use product.
Possible mitigation options include: demand reduction for single-use bottles in the first place, alternative
solutions to eliminate single-use bottles, opportunities for manufacturers to address product design, impetus for
policy makers to act on coherent labelling systems for materials and improved overall waste management.
Considering the level of confusion at hospital and household levels as to best practice in recycling, this research
highlights the need for targeted collaborative research utilising sectoral best practice, waste hierarchy and
circular economy principles.

1. Introduction the medical sector has focussed on comparing single-use with available
reusable products in terms of quality of performance and lifecycle
Plastic pollution is one of the biggest environmental problems to be analysis (Buléon et al., 2013; Campion et al., 2015; Marfin et al., 2003;
tackled on a global level, with the durability of plastics presenting many McGain et al., 2012, 2009). With an ever-increasing amount of single-
challenges including being a significant threat to human health use plastics employed in healthcare and medical settings, this paper
(Landrigan et al., 2018; The Lancet Planetary Health, 2018). Single-use aims to analyse the management of plastic waste arising from ready-to-
plastics constitute one of the most concerning parts of the plastic pro- use (RTU) infant formula bottles and teats in maternity hospitals in
blem as they are primarily derived from oil, and, if not recycled end up Ireland.
in landfills, or worse in the marine ecosystem. The EU have made strong
declarations of intent to tackle marine litter by banning single-use 1.1. Challenges in plastic waste management: from global to Irish levels
plastics where alternatives are readily available and affordable. For
products without alternatives, limiting their use will be achieved The challenges of plastic waste management are brought to public
through “reduction in consumption; design and labelling requirements attention through mainstream and social media e.g. by 2050, there will
and waste management/clean-up obligations for producers” (European be more plastic in the ocean than fish (Wearden, 2016). With the global
Commission, 2018). Emergent research on single-use plastics waste in plastics demand and production rising every year, the Ellen McArthur

Abbreviations: ALU, aluminium; BBP, benzyl-butyl phthalate; DBP, Di-n-butyl phthalate; DEHP, Di(2-ethylhexyl) phthalate; DiBP, Diisobutyl phthalate; HDPE, high
density polyethylene; LDPE, low density polyethylene; PET, polyethylene terephthalate; PP, polypropylene; PS, polystyrene; PVC, polyvinyl chloride; RIC, resin
identification code; RTU, ready-to-use; WEEE, waste electrical and electronic equipment; WFD, waste framework directive
⁎
Corresponding author.
E-mail address: yvonne.ryan@ul.ie (Y. Ryan-Fogarty).

https://doi.org/10.1016/j.resconrec.2019.104462
Received 5 March 2019; Received in revised form 13 July 2019; Accepted 23 August 2019
Available online 02 September 2019
0921-3449/ © 2019 Elsevier B.V. All rights reserved.
S. Leissner and Y. Ryan-Fogarty Resources, Conservation & Recycling 151 (2019) 104462

foundation reports that currently there are 8 million tonnes of plastics

leaking into the ocean every year which will quadruple up to 2050 if no
action is taken and a business as usual approach is kept instead
(Wearden, 2016). Eriksen et al. (2014) estimate the minimum number
of floating plastic particles and their associated weight in the oceans to
amount to 5.25 trillion particles. To tackle the problem on a global
level, 69 associations in 35 countries have signed the Declaration of the
Global Plastics Associations for Solutions on Marine Litter working to-
gether on over 260 projects ranging from beach clean ups to increased
waste management capacities, and research to further support aware-
ness and education campaigns (Marine Litter Solutions, 2018). How-
ever, Ireland is not yet a participant.
Only about 30% of plastic waste generated in Europe in 2014 was
recycled (PlasticsEurope, 2016) which could lead to severe environ-
mental impacts such as toxic components leaching into soils and
aquifers, or ultimately furthering marine litter generation. Fig. 1. Resin identification codes. Source: Minnesota Pollution Control Agency,
Major obstacles to recycling tend to be low economic values, con- 2013.
taminated material, pieces too small for easy collection or products that
contain multiple materials that cannot be separated (Rawlings and recyclability is an obvious obstacle, particularly for the everyday con-
Pora, 2009). Often recyclable polymers also do not reach a critical mass sumer because products in a time of globalised economies are rarely
in waste streams which makes economically viable recycling even more made and distributed on a national level only, but rather sold, used and
difficult (d’Ambrières, 2019; Hopewell et al., 2009). Even where scale is therefore ultimately disposed of in various countries worldwide.
achieved, further difficulties arise in producing plastic resins because Recyclable waste can either be taken to a recycling facility or be
different plastic types are not compatible due to “inherent immiscibility collected via kerbside collection. As Hopewell et al. (2009) points out,
at the molecular level” (Hopewell et al., 2009). Taking the obstacle of ‘bring-schemes’ only produce higher collection rates with a highly
contamination, Marcinkowski and Kowalski (2012) assessed the prof- committed public or through economic incentives, such as e.g. the
itability of washing food packaging waste before recycling in a house- German Pfand system (see section 4.2). Following the general trend of
hold context and only found washing glass waste to be within their best kerbside collection, the following recyclables are all grouped together
results, not plastic. For a corporate context Aarnio and Hämäläinen to be collected together within the recyclable bin in Ireland: “Recycl-
(2008), illustrated this further with numbers for fast food packaging. able materials include paper and card, all rigid plastics regardless of the
Despite a calculated 93% theoretical recovery rate for packaging waste, colour, number or symbol, aluminium, tins and cans” (Government of
only 29% is recovered. Of the remaining 64% nearly half, 33%, would Ireland, 2019). The Irish Government launched a dedicated website,
be achievable with improved waste management practices. www.mywaste.ie, to guide household recycling. With respect to plas-
Specific to Ireland, the challenges in attaining desirable recycling tics, consumers are advised that hard plastics such as bottles and plastic
rates are illustrated by reports that in 2016, 160 containers holding food trays are to be placed in the recycling collection, whilst soft
contaminated recyclable waste destined for China were rejected and plastics and film are to be placed in the general waste collection as they
returned to Ireland (Ring, 2017). Shipments of plastic waste sent to are not currently recyclable in Ireland despite being acceptable for re-
other countries for incineration, together with waste incinerated in cycling in other jurisdictions.
cement kilns or put into landfills, make up 65% of plastic waste in
Ireland that is not recycled, while only 35% is recycled to begin with
(Flynn, 2017). 1.2. Opportunities for plastic waste management
Another reason put forward for the poor uptake of recycling is the
incoherent and misleading labelling system currently in place (Circle Considering the difficulties faced within current recycling practices,
Economy, 2015; Hunt et al., 2015). In the Irish context this has been the problem moves from how to successfully recycle towards the more
highlighted in recent reports regarding confusion amongst the general important issue of avoiding plastic wastes before they are created. This
public in Ireland with respect to recycling labelling (Flynn, 2017). means following the waste hierarchy as set out in the European Waste
While consumers widely believe the green dot symbol with two arrows Framework Directive (WFD) in ranking prevention of waste highest,
in a circle as used on products sold by Repak members (the Irish Pro- superseding reuse, recycling, recovery and waste disposal (Council
ducer Compliance Scheme) indicates that the product is recyclable, that Directive, 2008). Through the WFD as well as the Circular Economy
does not necessarily have to be the case. The green dot only means the Package, EU member states are encouraged to examine waste man-
company putting the product on the market has paid the national agement with a life cycle perspective (Eriksen et al., 2014). Even
producer compliance scheme that funds packaging recycling in Ireland. though circular economy practices such as reuse, waste prevention and
The Mobius sign of three arrows in a triangle on the product denotes eco design are estimated to save EU businesses up to 600 billion Euros
whether a material can be recycled (Flynn, 2017). Some brands are (European Commission: DG Environment, 2014), implementation of
voluntarily labelling their products as to which components are circular economy principles may prove to be hindered by an excess of
(widely) recyclable, however it is neither compulsory nor is there a diverging approaches (Kalmykova et al., 2018).
global standardised system that facilitates coherent branding (Flynn, Ultimately, the sheer quantity of waste cannot be managed in ways
2017). As presented in Fig. 1, Europe and America tend to use the resin appropriate for the environment or oceans, the reduction of plastics at
identification code (RIC) system which labels the seven most frequently the beginning of the life cycle becomes integral to resolving these is-
encountered plastic types (American Chemistry Council, 2017). sues. European plastic demand in 2015 flags the two largest sectors
Many more commonly used polymers are in circulation and this is requiring plastic materials, they are packaging with 39.9% and “other
reflected in the much broader polymer identification system from sectors including health and safety needs” with 22.4% (PlasticsEurope,
China. The Chinese system describes not only the seven different classes 2016).
of plastics, it outlines five different post-consumer paths and en-
compasses 140 identification codes (Hunt et al., 2015). The absence of a
global identification system of materials and account of their

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1.3. Plastic waste in hospitals

In US hospitals alone, 20–25% of the 14,000 tons of waste created

per day consists of plastic packaging or plastic products (Lee et al.,
2002). Analysing the recycling potential of plastic waste in eight hos-
pitals, Lee et al. (2002) found the biggest recycling potentials to be
within operation rooms and the cafeteria while facilities such as patient
rooms had the lowest recycling potentials. An important obstacle to
recycling in a hospital setting is found to be separating general waste
from infectious waste that is unavailable for recycling due to health and
safety regulations (Lee et al., 2002; McGain et al., 2009), thus ex-
plaining higher recycling potential in a low risk environment such as
the cafeteria.
For segregation of recyclable materials in medical environments to
be successful, a Dutch study on circular streams of plastics in hospitals
called for research to determine if commonly used plastic types such as
“PET and HDPE plastics meet the requirements for sterilisation, safety,
preservation, etc. of medical equipment used in the healthcare in-
dustry” (Circle Economy, 2015). There may be a need for efforts from
all stakeholders involved to find an ideal plastic type and address the
overall obstacle of proper signage for hospital settings. The Dutch study
concluded that transparency and coherent printing of plastic codes on
medical plastic products is needed for successful recycling. Another
major barrier to recycling in hospitals as well as in any other en-
vironment is the use of mixed plastics within one product, which often
aggravate or even prohibit recycling (Circle Economy, 2015).
Up until now, the available research about waste management for
single-use plastics in hospitals has focused on in-hospital use, drawing
the boundary at hospital doors, yet patients may continue to use the
exact same products outside of the hospital confines (Chauhan et al.,
2019; Sookne, 2018; Stringer et al., 2018). This paper is one of the first
of its kind to examine single-use plastics in hospitals and domestic
Fig. 2. Diagram of bottle parts.
environments (when parents continue using the ready-to-use infant
formula bottles at home after the first few days at the hospital), hence
providing an even bigger potential societal impact for private and 2. Methods
public policies developed to tackle the use of single-use plastics.
2.1. Categorisation of single-use plastics in ready-to-use infant formula milk
bottles and teats
1.4. Purpose of this paper
There are three different ready-to-use (RTU) infant formula milk
This paper presents data collected at two maternity hospitals in bottle brands commonly used in maternity hospitals in Ireland. One
Ireland. Single-use ready to use (RTU) infant formula bottles are a bottle brand as representative of the three was chosen; it is one of the
significant waste stream within these hospitals generating both food two brands that use identical packaging. At the time of data collection,
and packaging wastes (Ryan-Fogarty et al., 2017). Ireland has one of the third brand was in the process of developing a plastic instead of a
the lowest breastfeeding initiation rates in the world. from data pub- glass bottle. The teat chosen for analysis was also the most commonly
lished in 2016, only 46.3% of babies were exclusively breastfed in used one of the brands available.
maternity hospitals (Health Service Executive, 2016), meaning that > Three used sample bottles of the chosen brand were gathered from
50% receive infant formula. Ireland produces 10% of all infant formula site visits to be examined. After opening the bottles and taking them
consumed across the world (Donnelly, 2018). Ireland is China’s second apart entirely, all parts as illustrated in Fig. 2 were cleaned carefully.
largest supplier of infant formula as food scandals drive demand for The bottle sealing as described in Fig. 2 means the very thin plastic
standardised and organic products in the Asia region (Cadogan, 2017; layer attached to the main bottle holding branding and product in-
FIBL and IFOAM Organics International, 2017). It was not possible to formation. This was not detached from the bottle as it would not nor-
determine how much of the infant formula global market, estimated at mally be removed by the customer. At the time of sample collection, the
$5-6 billion (Donnelly, 2018), was attributable to ready to use bottles. management of these wastes were noted and recorded.
However, recent years have seen increased production as RTU infant The approach to identify the materials used was examination of the
formula bottles become available to buy in supermarkets and on-line, parts, online research and consultation with experts in researching
with in-hospital brand recognition playing a part in driving sales plastics. A chemical examination in the laboratory was not performed,
(Cattaneo et al., 2014). this is due to the principle that it should not be necessary to undertake a
The quantity of these bottles and teats used in Ireland over the full chemical analysis for customers either. All materials were expected
timespan of one year for a low use scenario are presented using data to have enough identifiable markings to allocate them to existing
from Ryan-Fogarty et al. (2017). A material analysis details the com- groups of identifiable plastics such as the internationally recognised
position of single-use bottles and teats and recycling options are in- Plastic Packaging Resins as depicted in Fig. 1. As the bottle sealing and
vestigated and presented. Possible alternatives to mitigate the current lid ring were practically impossible to detach from the main bottle by
trends in plastics waste arising from single-use plastic RTU infant for- hand, they were weighed together with the main bottle. The teat in
mula bottles are presented. packaging is the trio of parts that are separate to the main bottle at first
but are then attached to feed an infant.

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2.2. Quantification of plastics from ready-to-use infant formula milk bottles above.
and teats The difficulties that arise with lack of proper signage appear to be
common especially in imported, low cost products (Malcolm Richard
The dismantled and cleaned parts of all three sample bottles as et al., 2011), and are widely acknowledged as one of the initial barriers
described in section 2.1 were weighed to determine the average weight to correct separation at the post-consumer level (Circle Economy, 2015;
of each part. As mentioned above, the sealing that is wrapped around Hunt et al., 2015): Without distinctive labels or symbols showing ex-
the bottle itself as well as the lid ring left on the bottle’s neck after actly which waste treatment path to use, the consumer could be left
unscrewing the lid were impossible to remove by hand. As they were without information or guidance and hence cannot act appropriately.
highly unlikely to be removed by health care staff or parents to recycle Another component that could not be determined by simple ex-
the different parts separately, these three parts are weighed and amination due to missing labelling, was whether the product was free of
counted as one ‘plastic bottle’. any phthalates commonly used to soften plastics, such as hazardous
There are 5 maternity hospitals and a further 14 general hospitals BBP, DBP, DiBP, or DEHP. With toxic health effects on liver, re-
that have maternity units or wards in Ireland, sperate to infants in productive organs and kidneys, these four phthalates must be author-
paediatric hospitals and wards. The method to calculate the overall ised if used in percentages higher than 0.1%. However, as Lee et al.
amount of the different parts of the RTU infant formula bottles used in (2014) point out, as part of a circular economy there is a chance that
these healthcare facilities is based on the low use scenario as developed these toxins may re-enter the product life cycle of, for example, food
by Ryan-Fogarty et al. (2017): packaging in higher proportions. Recycled materials can be excluded
from registration obligations if they meet a minimum of 80% of the
• “Neonatal and perinatal deaths are not subtracted from live births main constituent being of the same material as previously registered
for 2013, the number of infants feeding is reported as 68,830. hence leaving a full 20% simply considered as impure material to be
• Infants that are artificially fed or partially breastfed receive one of recycled again without registration.
the three main brands of infant formula purchased by the maternity Absent from Table 1 above is the thin lid used for the teat packa-
services. Brand use is assumed to be evenly split and so the average ging, which was the only piece together with the thin layer of cover
volume per bottle is taken to be 80 ml. Specialist or other milks and around the main bottle that was lacking any code at all. It was assumed
fortifiers are not included in these calculations. that this lid was most likely made of a similar material to Tyvek,
• Only the 8 bottles allocated per infant are considered. Spilled, out of commonly used in healthcare packaging as it is an effective sterile
date and opened but unconsumed bottles (outside of the allocated 8) barrier (DuPont, 2017). Tyvek as a waste product could be assigned to
are not included as there is no available data on which to base a the group of plastics recyclables under the second group of RIC plastics,
calculation. HDPE.
• The low use scenario assumes that infants who received breast-milk In both hospitals, used bottles were collected by healthcare assis-
but are not exclusively breastfed each received only 1 bottle on day tants and brought to “sluice rooms” where waste infant formula was
1 of life.” poured out and the bottles were rinsed. In one hospital, waste milk was
washed down the sink while rinsing the bottles for recycling. In the
The total number of bottles and teats required in the low use sce- other hospital, to lower the biological oxygen demand of wastewater,
nario is 787,057. waste infant formula was collected in compostable receptacles and re-
moved to the food waste collection on site.
3. Findings and discussion In both hospitals the rinsing of recyclable plastics and glass bottles,
as advised by the national compliance scheme and regional waste
3.1. Categorisation and analysis of single-use plastics in ready-to-use infant management authorities (Government of Ireland, 2019; Repak, 2019),
formula milk bottles and teats created additional environmental impacts: water use and wastewater
generation. Nevertheless, rising of plastics was a clear instruction
Examination reveals the main six parts of the bottle to most likely be communicated to the public regarding best practice for recycling
built of the following plastic materials as shown in Table 1 and Fig. 3. (Government of Ireland, 2019). There was confusion surrounding dis-
The identification of materials used in the RTU infant formula posal of teats. The first hospital placed both bottles and teats in the
bottles was more difficult task than anticipated. It should not be this recycling collection whilst the other only the bottle was placed in the
problematic considering that an everyday user of these bottles should recycling collection. Soft plastics are not deemed recyclable in Ireland,
be able to identify the materials easily to see if they are to be segregated and, in both cases, the plastic bottle sealing containing the product
for recycling or if the whole product is recyclable as one. Identification information was not removed prior to bottle placement in the recycling
was found to be challenging mostly due to labelling issues. Even though receptacles.
it was assumed that the commonly used RIC system would be used, half Even though the bottle foil cap, made of aluminium, comprises the
of the parts were labelled using an entirely different system, making it smallest part of the bottle, aluminium may have a greater recycling
hard for the European customer to find out which recycling group the value than the rest of the plastic components. In European countries
parts should be assigned to. As outlined in Table 1, it was assumed that with appropriate national requirements and successful collection
the parts not coded in the RIC system were coded using the Chinese schemes, recycling rates for aluminium packaging reach up to 80%. The
codes for plastic products and hence signify the plastic materials listed costs for the recycling processes is covered by the value of the collected

Table 1
Bottle parts with correlating codes and materials.
Bottle part Classification within Recycling codes Identification as plastic material

Teat packaging Most likely Nr 8 in Chinese codes for plastic products, partly Tyvek-like material (recyclable with RIC #2) acrylonitrile-butadiene-acrylate plastic
Teat Most likely Nr 22 in Chinese codes for plastic products cellulose proprionate
Collar Most likely Nr 7 in Chinese codes for plastic products acrylonitrile-butadiene plastic
Bottle lid RIC #2 HDPE high density polyethylene
Foil cap RIC #41 ALU aluminium
Plastic bottle RIC #5 PP polypropylene

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Fig. 3. Bottle parts labelled with material composition.

waste products therein saving up to 95% of energy in producing the

material from recycling (European Aluminium Association, 2008).
The occurrence of the identified plastic materials in the overall
demand for plastics in Europe in 2014 was 12.1% for HDPE whereas PP
alone made up 19.1% (PlasticsEurope, 2016). These numbers might
lead to the expectation of high recycling numbers of the waste made up
of the same materials, “however, the use of recyclates is heavily de-
pendent on demand, which is influenced by the price of virgin material
as well as the quality of the recycled resin” (European Commission (DG
Environment), 2011). With these acknowledged obstacles to recycling,
the European Commission indicates that the use of recycled materials
instead of virgin materials is still only marginal for all plastic types.

3.2. Quantification of plastics used throughout maternity wards in Ireland

The tonnes of waste generated for each part of the bottles are cal-
culated and presented in Table 2, the results in percentages are shown
in Fig. 4; values in Fig. 4 are shown for the whole of Ireland per one Fig. 4. Bottle parts and percentage composition by weight.

Table 2 year given in relative percentages for the low use scenario.
Weight of waste generated from each bottle part per annum in Ireland under the The amount of waste created with the main part of the plastic bottle
low use scenario. made up of PP alone sums up to eight tonnes. The second highest
Material Name Average mass Total waste generated in one year of the ranking, the collar and teat of the bottle are both made of materials
[g] low use scenario [t] lacking any European or Northern-American signing. Hence Fig. 3
shows the importance of proper labelling. Together with the packaging,
Teat in packaging 8.41 6.62
Packaging 1.61 1.27
40% of the waste generated through these small bottles alone is made
Teat 3.03 2.38 up of materials that do not bear any recycling codes rendering it dif-
Collar 3.77 2.97 ficult for the everyday user to manage them properly.
Bottle lid 1.99 1.56 The results of this research on one niche product alone show that if
Foil cap 0.30 0.23
materials were labelled coherently and recycling practices more widely
Plastic bottle 10.62 8.36
adopted, even a product as small as an RTU infant formula bottle could

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possibly improve the recycling rate of a highly demanded material such loop, e.g. exchange of experiences and training of staff and subse-
as aluminium. This could provide future opportunities in improving quently parents on how to dismantle and dispose of single-use plastics
material and energy flows for these products. Instead of relying on re- correctly. Procurement policies need to accurately reflect healthcare
sourcing and creating new virgin plastics and all associated environ- priorities and seek ways to eliminate, reduce and mitigate waste
mental impacts along with it, the previous waste materials could be wherever possible.
used as new resources instead. Increased consumers demand for standardised and organic infant
Even though the foil cap has the lowest numerical mass value, formula may be pre-emptive of a trend, concern regarding the impacts
aluminium is more valuable than plastic and is known to be recycled of single-use plastics may lead to demands for alternative approaches.
easier by the public if consumers are aware and educated on the matter.
Because the foil cap is so small and light, it can be left behind on food 4.2. Implications for policy makers
trays, thrown into the general waste or seldomly be screwed back onto
the empty bottle with the plastic lid after consumption. This exemplifies Taking the results of this research and the current literature into
the difficulties of waste management. account, a standardised labelling system for all plastics should be made
The numbers shown in Table 2 and Fig. 4 are for the maternity mandatory through legislation. Even though consumers in Ireland are
services in Ireland and represent conservative calculations of use. These advised to put “all rigid plastics regardless of the colour, number or
bottles are also used in paediatric care in hospitals throughout Ireland symbol” (Government of Ireland, 2019) into the recycling collection,
where infants may remain as patients for considerably longer periods of there is still confusion left as to how far “rigid” goes. Taking the ex-
time. The same bottles can also be purchased by the public in super- ample of this bottle, one does wonder if the teat packaging, its lid, the
markets and on-line. As effective recycling is evidenced to only be teat itself or the bottle sealing still fall under this category or if the
feasible on a large scale (Hunt et al., 2015; Lazarevic et al., 2010; bottle would have to be disassembled into recyclable and non-recycl-
Malcolm Richard et al., 2011), it is necessary that all recyclable plastics able parts. Perfect labelling of each polymer type may not be needed at
are correctly managed and are collected in systems that permit effective a customer level, but what is needed is a standardised labelling system
recycling with minimal contamination. This is particularly challenging indicating if a product is entirely recyclable or if it only has some re-
in a healthcare environment, where patient safety takes priority. In cyclable parts and therefore needs to be disassembled before recycling.
addition, hazardous wastes such as sharps and hazardous materials tend Recently, the EU set stronger labelling requirements and targets for
to be the focal point of staff training and awareness. This highlights the “sanitary towels, wet wipes and balloons” (European Commission,
need to return to focus efforts to prevent these wastes from arising in 2018), but as this research has demonstrated, labelling is required for
the first instance as per the waste hierarchy. many more products. In general, increased campaigns for correct re-
cycling chains, alternative reusable products and negative impacts of
4. Implications of research single-use plastics to further empower the public are needed to improve
the situation. There is no binding policy as to which product groups the
4.1. Alternatives to SUPs in the hospital setting EU would like to focus such campaigns on, but it is rather left up to each
member state to execute its own campaigns (European Commission,
As per the waste management hierarchy the most desirable outcome 2018). Furthermore, governmental bodies could reach out to and link
is an avoidance of such plastic waste generation in the first instance. To up with other sectors (local authorities, education, housing etc.) in their
avoid use of single-use RTU infant formula bottles and teats, dedicated reach. If the same recycling/waste collection system is set up nation-
support systems for healthcare professionals and parents highlighting wide or better still European/worldwide, people would get accustomed
the importance of breastfeeding thereby avoiding waste through in- to and are more likely to take waste management knowledge and ac-
creasing exclusive breastfeeding rates. Ireland has one of the lowest tions home. Outside of state institutions, packaging producers can be
exclusive breastfeeding rates in the world (Purdy et al., 2017). In- legally obliged to be part of the same circular economy and waste
creased exclusive breastfeeding rates, which is also a national public management system preventing products ending up as waste in the first
health priority (Ireland, Health Service Executive, 2012), should reduce place. An already very successful example for this is the German Pfand
overall demand for these products. Controlled practices regarding deposit refund scheme for both single-use drink packaging (Einwegp-
bottle distribution and research to optimise stand time guidance are fandflaschen = One way deposit bottles) and multiple use drink
additional options, as, currently bottles are disposed of after one hour packaging (Mehrwegpfandflaschen und dosen = More way deposit
after opening regardless of whether the contents have been consumed bottles and cans). The single-use containers such as soft plastic bottles
or not. or metal cans have a higher deposit of 25cts, more solid multiple use
Alternatives to single-use RTU infant formula bottles are the use of containers such as hard plastic or glass bottles or glass beer bottles with
glass bottles and standard teats that are reusable after sterilisation; the a swing-top have a deposit of 15cts and the simple (beer) glass bottles
preparation of powdered infant formula or decanting of bulk liquid RTU have a deposit of 8cts (AK Mehrweg GbR, 2019).
formula and use of human donor milk instead of the single-use plastic The focus should be placed on recycling parts that are valuable (i.e.
bottle infant formulas. There would be additional environmental and the foil cap) and parts that have value i.e. the plastic collar and bottle.
health benefits to these approaches such as a reduction in food waste Less focus should be placed on recycling relatively low weight con-
and parents becoming educated on correct bottle preparation before stituent parts that lack recycling codes (i.e. packaging for teats).
they leave hospital. As with all possible alternatives, this group of re- The birth of a child is a key life event, resulting in new consumption
commendations requires consideration and planning to incorporate patterns and opportunities for change. Opportunities exist to educate
infection control measures. new parents on waste avoidance, correct recycling and disposal
Overall improved waste management systems in a hospital setting is methods. Increased sensitivity and knowledge about single-use plastics
a subject for further research. It will need the creation of an easy-to- recycling may positively spill over into other recycling behaviours e.g.
understand and easy-to-use recycling system. This includes involvement food waste and WEEE (waste electronic and electrical equipment) that
of all stakeholders along the life cycle such as hospital staff and waste could last for much longer periods of time than the time surrounding
contractors. A closed loop system with the manufacturers responsible infant feeding.
for collecting waste packaging associated with their product could de-
crease need for new virgin materials and resources and would cut out 4.3. Implications for manufacturers
transportation between a middle agent such as the waste contractor. In
any case the current recycling system should encompass a feedback Implications for manufacturers include the re-design of products,

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S. Leissner and Y. Ryan-Fogarty Resources, Conservation & Recycling 151 (2019) 104462

where single-use plastic RTU bottles are necessary, singular polymer Declaration of Competing Interest
types minimising other materials should be prioritised. If multiple
materials need to be used, manufacturers could make sure to combine The authors declare that they have no known competing financial
chemically compatible sources for combined recycling purposes. If interests or personal relationships that could have appeared to influ-
multiple types of plastics are needed, the design should incorporate that ence the work reported in this paper.
products could be easily taken apart. If the dismantling is too compli-
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