The Case for Chewable Tablets: Reducing Single-Use Plastic Waste in Pediatrics

Corresponding Author Lydia Lu; Children’s Healthcare of Atlanta, 2174 North Druid Hills Road NE, Atlanta, GA 30329;Lydia.lu@choa.org Funding No funding source. Conflict(s) of Interest All authors have declared no conflict of interest. Background An estimated 3000 tons of plastic are discarded by US hospital systems daily, the majority as single-use plastics (SUP).1–3 Plastics contain chemicals potentially harmful to children, and are sourced from oil and gas. When plastics are disposed in landfills they emit methane, a greenhouse gas which contributes to climate change. Not all plastics can be avoided, but many practices can be modified to safely decrease SUP use. We sought to quantify the amount of SUP waste created with administration of the three most prescribed pediatric medications: acetaminophen, ibuprofen, and amoxicillin, which is the antibiotic most frequently prescribed to children. Methods Children’s Healthcare of Atlanta is a pediatric hospital system with three free-standing hospitals. We took an inventory of all acetaminophen, ibuprofen and amoxicillin doses to pediatric patients from 2-21 years of age in 2024 by our hospital pharmacies and categorized them by liquid versus tablet formulation. We also weighed the SUP items utilized to dispense these medications: 10 cc syringes with caps (4.4 g), pre-dosed plastic medication cups for acetaminophen and ibuprofen (2.9 g), plastic transportation trays per 10 pre-dosed cups (20 g), small plastic ziploc bags (1.6 g), and plastic medication cups (1 g). According to standard operating procedures (SOPs), liquid formulations of oral medications are dosed by weight and drawn into SUP syringes. Manufacturer pre-dosed plastic cups are stocked in automated medication dispensing machines in hospital units. Nurses access the cups, draw out the appropriate dose by syringe and dispense the medication to the patient. Unused drug is wasted. Amoxicillin liquid doses are prepared by the pharmacy, labeled, secured in individual plastic bags, and sent to patient care areas where the syringe is used to administer the medication. Acetaminophen and ibuprofen tablets are re-packaged by the pharmacy into plastic and paper blister packs, then stocked in hospital units. Nurses obtain the tablets from the automated medication machines and transfer the appropriate dose from the blister pack to a plastic medication cup for presentation to patients. Tablet formulations for amoxicillin are dosed into a small plastic bag sent from the pharmacy to hospital units where the medication is transferred to a plastic medication cup for administration. The estimated plastic waste per dose of drug by formulation is summarized in Table 1. The impact of the SUP waste created by dispensing these three medications (acetaminophen, ibuprofen, and amoxicillin) for one year in our hospital system was estimated using the conversion factor of 3.10 kg of CO2 equivalent emissions per 1 kg of plastic waste, per the UK Centre for Sustainable Healthcare.4 Results In 2024, 86 216 doses of acetaminophen, 74 000 doses of ibuprofen, and 11 368 doses of amoxicillin were dispensed to patients 2-21 years old. Of these, 59.6% (n = 53 135) of acetaminophen, 68.4% (n = 50 656) of ibuprofen, and 59.6% (n = 8652) of amoxicillin doses were given in a liquid formulation. For preparation of liquid medication doses, the estimated total weight of the plastic used was 1017 kg, equivalent to 3153 kg of CO2e emissions. In contrast, the estimated total weight of the plastic associated with tablet dispensing was 66 kg, equivalent to 206 kg of CO2e emissions for the same period. If all liquid doses of amoxicillin, ibuprofen and acetaminophen had been given as tablets, a total 891 kg of plastic waste, equivalent to 2762 kg of CO2e emissions could have been spared. If paper cups were used instead of plastic cups for dispensing tablets, an additional 62 kg of plastic waste, or 192 kg of CO2e emissions could have been spared. The combined 2824 kg CO2e emissions saving potential is approximately equivalent to driving 7191 miles in a gas-powered vehicle.5 Conclusion Despite the availability of chewable tablet formulations and stair-step dosing recommendations for acetaminophen, ibuprofen and amoxicillin, most of these medications were administered to our patients as liquid formulations, generating substantially more SUP waste than tablet administration. Additional SUP waste could be decreased with a change to paper cups rather than plastic. Innovative approaches to further eliminate the need for SUP for medication administration should be explored. Hospital systems have the potential to significantly reduce greenhouse gas emissions by strategically considering their utilization of SUP for medication administration and updating their standard operating procedures.