WW-05960     Revised 1992  

Waste Education Series

Infant Diapers and Incontinence Products:
Choices for Families and Communities

Sherri A. Gahring, Thomas R. Halbach, and Wanda W. Olson

Copyright ©  2012  Regents of the University of Minnesota. All rights reserved.

Introduction

Disposable diapers and incontinence products have been widely adopted for babies and for adults with bladder control problems. Alternative choices are cloth reusable products laundered either at home or through diaper/laundry services. Total sales for infant diapers and incontinence products were about $4 billion in 1990 in the United States (Consumer Reports 1991). Packaged Facts, Inc., estimated the sales of incontinence products (retail and institutional) to be $563 million in 1990 with retail sales being $263 million.

The choice of diapers and incontinence products has short-term and long-term effects on the individual, the family, the community, and the world. When consumers make choices, they allocate time, energy, money, and natural resources. These are based on personal needs, lifestyle, and values, and involve many trade-offs. While consumers primarily are concerned with convenience, cost, performance, and health, an additional concern is the fact that all product choices affect the environment. This publication discusses some of the issues and provides you with information to weigh the relative advantages and disadvantages of the various diaper and incontinence products¹.

Consumer Reports (1991) estimates that a child wearing disposable diapers uses 6,000 before being toilet trained. Infants and small children with diarrhea may use nine to eleven diapers per day whereas a child nearly trained may use only one or two. Procter & Gamble (1986) in a diary study found that a child wearing disposables uses an average of 5.4 diapers per day, 7.2 for the first three months; several sources suggest that 9.7 cloth diapers are needed per day. Cloth diapers may be doubled for greater absorbency and are changed more often than disposable diapers. A 1990 study of diaper service users reported an average daily use of 7.2 cloth diapers and 0.7 disposable diapers (Lehrburger et al. 1991).

Urinary incontinence, the involuntary loss of urine, is a major clinical problem and a major cause of disability and dependence. It affects all age groups but is particularly common in the elderly. At least 10 million adult Americans are incontinent, including approximately 15 to 30 percent of older persons living at home and at least half of all nursing home residents. About 15 percent of people over 50 years of age have some degree of incontinence (Private Label 1991). In a survey of persons with incontinence, Jeter et al. (1990) found that 10.6 percent had continuous leakage, 21.0 percent experienced incontinence many times a day, 41.4 percent experienced incontinence once or a few times per day, and the remainder experienced incontinence less than once per day. The potential costs associated with urinary incontinence include decreased self-esteem, restricted social involvement, rashes and skin irritation, an increased likelihood of medical attention and care, increased laundry costs, and a decreased useful life of chairs, sofas, and carpeting (Herzog et al. 1989).

Products

Infant Diapers

There are more reusable and disposable diapers available today than ever before. Products vary in design and fabric, in absorbency and fecal containment, and in durability, comfort, convenience, cost, and drying speed.

There are three types of diapers or diapering systems currently available: 1) cloth diapers with or without a wrap or pants; 2) "all-in-one" cloth diaper systems, which include both an inner cloth lining/padding and an outer waterproof covering; and 3) disposable diapers.

Cloth diapers are almost always made of cotton. Fabric weaves to choose from include bird's-eye, flannelette, terry cloth, and gauze (the most common). Gauze diapers are available in daytime and nighttime weights; the usual size is 21 x 40 inches, which can be folded to fit a baby throughout the diaper-wearing period. Double-sided diapers made of cotton flannel and terry cloth are another alternative.

Prefolded and preshaped cotton diapers also are available with features such as Velcro ® closures, elastic legs, and a polyester fiber liner or a center panel made of several additional fabric layers for extra absorbency. They are convenient but in some the size cannot be significantly adjusted.

Breathable wraps or covers to put over the cloth diaper are available in nylon, polyester, cotton, wool, or Goretex R, including some that have a wetness barrier. Many styles feature Velcro ® closures and elastic or fitted legs and come in various sizes.

One-piece diaper systems, which include an inner cloth padding and an outer waterproof covering, offer the advantage of being removed all in one step like disposable diapers. This makes diaper changing more convenient. Some design features include Velcro ® closures to eliminate the need for pins, elastic legs and waists for better fit, several layers of cotton padding, and an absorbent vinyl layer. For extra absorbency some styles include an inner flap to hold a diaper liner. One-piece systems cost $5.00 to $10.00, and are available in several different sizes.

Disposable products for babies include diapers, liners, and training pants. Some design features are:

• refastenable waist tapes
  
  
• elastic waists
  
  
• double elastic legs
  
  
• leakage control inner shields
  
  
• gender-specific absorbent zones
  
  
• solid colors or prints
  
  
• small to extra-large sizes
  
  

Most superabsorbent diapers contain a water-holding gelling material to maximize absorbency and keep wetness away from the skin. This gelling material comes in a granular form and turns to a gel when it comes in contact with urine.

Incontinence Products

While there are many products on the market to assist an individual in managing urinary incontinence, it should not be assumed that incontinence products are the only alternative. For many persons, incontinence can be treated.

Persons with urinary incontinence should first report their symptoms to a physician who can provide assessment, diagnosis, treatment, or referral. An E.T. nurse (specialist in urinary and fecal incontinence) can assist in developing a comprehensive program for individuals with incontinence, including selection and use of appropriate products and prevention/treatment of skin breakdown.

This report focuses on moisture-absorbing incontinence products, disposable and reusable. Both disposable and reusable incontinence products are available in a variety of styles including shields and liners, underpads, briefs, and undergarments. They are made of various combinations including:

• plastic film or coated nylon for a waterproof backing
  
  
• paper fiber, gelling material, or cotton gauze/flannel for a middle absorbent layer
  
  
• nonwoven or woven or knitted fabrics made of polyester, olefin, viscose or cotton for the coverstock (Dallas and Wilson 1992, HIP, Inc. 1990)
  
  

The retail sales of disposable moisture absorbing products by percent of the market are shown in Chart 1. Some design features available in disposable products include:

• elastic legs
  
  
• varying absorbency levels for different bladder control needs
  
  
• absorbency systems to keep wetness away from the skin
  
  
• liners, pads, or drip collectors with peel-back adhesive
  
  
• high waist fit
  
  
• refastenable waist tapes or reusable elastic belts
  
  

Chart 1. Breakdown of retail market for disposable incontinence products. 1
Undergarments	36.4%
Briefs	24.1%
Shields	20.5%
Underpads	16.9%
1Private Label (1991). Numbers do not add to 100% due to rounding error.

Some design features available in reusable products include:

• elastic legs
  
  
• Velcro ® or snap side closures
  
  
• waterproof inner layer
  
  
• waterproof crotch panels
  
  
• liners and pads held in place with loops, snaps, or pockets, or adhesive backing
  
  
• high waist fit
  
  

Both disposable and reusable incontinence products vary in their performance. Even though a product may be advertised as having "maximum absorbency," it may not be as absorbent as other similarly advertised products. Dallas and Wilson (1992) evaluated and compared the excess skin wetness and moisture retention of 19 disposable and reusable product patches and found that product label terms used to describe "absorbency" properties were inconsistent indicators of product performance. Currently there are no standards for consistent product label terminology for incontinence products.

Many individuals with incontinence use other products instead of those specifically designed for incontinence. In a study by Jeter and Wagner (1990), disposable adult diaper products were used by 19.3% of the respondents and cloth adult diapers were used by 4.1% of the respondents. Other persons used other products designed for incontinence such as indwelling or external catheters but more often used products that are not designed for incontinence such as sanitary napkins, paper towels/tissues, and disposable baby diapers. Although there is an environmental impact associated with the use of these products, the focus of this report is on moisture-absorbent products specifically designed for incontinence.

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Health Issues

Infant Diapers

Health issues for babies relate to the condition of the skin and to the transmission of infectious diseases.

Diaper rash occurs frequently in diapered children. A major cause is prolonged contact with urine and stool or both. Changing diapers more often, regardless of the type of diaper used, will reduce the frequency and severity of the problem. Research shows that diapers that help keep skin dry and at normal pH can help reduce the chance of diaper rash for many infants (American Public Health Association 1992; Berg 1988; Campbell et al. 1987; Davis et al. 1989; Gaunder and Plummer 1987; Lane et al. 1990; Seymour et al. 1987b; Wilson and Dallas 1990). When selecting or using diapers, the following considerations can be helpful:

Disposable

• Disposable diapers have linings that wick moisture away from the skin.
• Superabsorbent disposable diapers promote skin dryness and normal skin pH better than other disposable diapers or cloth diapers (Campbell et al. 1987; Wilson and Dallas 1990).

Cloth

• Cloth diapers that use multiple layers of different fabrics are more successful in keeping the skin dry than are those that use multiple layers of the same fabric (Wilson and Dallas 1990).
• Cloth diapers with polyester sponge liners are better at retaining moisture and keeping a dry layer against the skin than are cloth diapers without liners (Theodore and Ferguson 1990).

Diaper System

• One-piece diaper systems and cloth diapers with separate waterproof pants/wraps are less successful in preventing leakage than are superabsorbent disposable diapers (Consumer Reports 1991).

The transmission of infectious disease is a major concern for out-of home care, especially when there are many children in one setting. To control the spread of disease, caregivers should reduce fecal contamination by hand washing, proper personal hygiene, and fecal containment.

In a recent study (Van et al. 1991) the fecal containment of disposable diapers was significantly better than that of cloth diapers with plastic pants. The use of a garment over a disposable diaper or a cloth diaper decreased the amount of fecal contamination of hands and surfaces. There was no statistically significant difference in fecal contamination between disposable diapers and cloth with plastic pants when overgarments were worn.

The American Academy of Pediatrics and the American Public Health Association recently adopted the following diaper standard for child day-care settings (American Public Health Association 1992).

3.1.E Toileting, Diapering, and Toilet Training
(July 3, 1991) ²

"Diapers worn by children shall be able to contain urine and stool and minimize fecal contamination of the children, caregivers, and environmental surfaces and objects of the child care setting. The diaper shall have an absorbent inner lining attached to an outer covering made of waterproof material that prevents the escape of feces and urine. The outer covering and inner lining shall be changed together at the same time and shall not be reused unless both are cleaned and disinfected. Three types of diapers or diapering systems are currently available; disposable paper diapers, reusable cloth diapers worn with or without a waterproof covering (pants or wrap), and reusable diaper systems with an outer waterproof covering and attached in cotton lining. Only modern disposable paper diapers with absorbent gelling material or carboxymethyl cellulose meet this standard. Reusable cloth diapers worn either without a covering or with removable, unattached pants or wrap made of waterproof material do not meet this standard. There are currently insufficient data to determine whether reusable diaper systems meet this standard...."

Incontinence Products

Health issues for adults relate to the condition of the skin. Health care professionals such as physicians and E.T. nurses should be consulted about the care of skin and the appropriate selection and use of all types of incontinence products. In one controlled study of nursing home residents, disposable products were more likely to improve skin conditions than were reusable products (Hu et al. 1990).

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Economic Costs

Infant Diapers

Many people assume cloth diapers cost less to use than disposable diapers whether they are washed using a laundromat, home facilities, or a diaper service. However, it is difficult to accurately compare cloth and disposable diapers. Families have their own ideas of how often babies need changing, how many diapers can be washed in one load, and the number and sizes of disposables that might be used. In addition, families may use both cloth and disposable diapers. It's easy to figure the cost of using the laundromat (though some calculations are needed for cost of time and transportation). But it's not so easy to figure the cost of doing laundry at home because you have to allow for cost and depreciation of laundering equipment, electricity, energy needed to heat the water, and time.

Table 1, Table 2, and Table 3 give some average costs to help you compare the costs of cloth and disposable diapers. Actual numbers will vary depending on whether one or two diapers are used per change, if the diapering period is longer or shorter, or if you consider other factors. If you do not consider cost of labor, cloth diapers washed at home or in a laundromat are more economical than disposable diapers or diaper service. If you do consider the cost of one hour of labor per week, the costs of the options are the same when labor is valued at $5.34 an hour.

Chart 2. Cost of reusable diaper supplies1
Cost of 6 dozen new cloth diapers	$79.94
Diaper wraps (2 waterproof covers)	$11.98
Waterproof plastic pants (6 pairs)	$10.74
Diaper pail (for soaking diapers)	$12.99
Sales Tax	$0.78
Total	$116.43
1These items do not need to be purchased new; for example, you may already have a covered utility pail that that can serve as a diaper pail. Special cotton diapers may cost $60 per dozen and up.

Cloth Diapers-Diaper Services. The cost for diaper services is based on the number of diapers reserved, not on the number used. In a survey of 37 operators and more than 500 customers, the average weekly order was 64 diapers (Lehrburger et al. 1991). The average customer for one Minneapolis/St. Paul diaper service uses 55 diapers per week. In January 1992 diaper service in the Minneapolis/St. Paul area cost $12.00 to $14.00 per week for delivery of 80 fresh diapers and pickup of soiled ones, ($10.00 to $ 11.50 for 60). Other costs include deposit for diaper pail and cost of diaper wraps and plastic pants.

Cloth Diapers Washed at Home or Laundromat. Cost estimates for cloth diapers washed at home or laundromat include the cost of diaper supplies and the cost of laundering. The cost estimate of reusable supplies, $ 116.43 (Chart 2), is an average from a few major discount stores in the Minneapolis/St. Paul area in ) January 1992. Households washing one load of diapers each day could purchase fewer diapers while those washing diapers weekly would have to invest in six or seven dozen diapers. Some households "double diaper" while others may use cloth diapers with an absorbent liner. Liners are not widely available in the Minneapolis/St. Paul area. Common costs are $.90/cloth liner and $.03/disposable liner. The cost of washing one load of diapers is given in Table 4. These per load cost estimates do not include the cost of time and transportation or the costs of water and sewage. The cost range for home laundry is $.82 to $1.49 and assumes $.28 per load for equipment depreciation. Cost per load for a laundromat ranges from $1.61 to $1.79.

Disposable Diapers. Costs of disposable diapers vary depending on the diaper size, package size, absorbency, and other features. The cost estimates in Table 5 represent an average of several brands from a few major discount stores in the Minneapolis/St. Paul area in January 1992. The number of weeks a child requires a particular size or number of changes per day will vary. Because of the wide variation in the cost of solid waste disposal, these costs have not been included in Tables 1-3.

Incontinence Products

Jeter and Wagner (1990) found that 80 percent of incontinent persons living at home spent less than $15.00 per month on moisture-absorbent incontinence products and only 6.6 percent spent $30.00 or more per month. Hu (1986) reports the cost per day of supplies and laundry for home care of persons with loss of bladder control to be $2.50 per day ($1.25 supplies, $1.25 laundry). One of the major cost savings of using incontinence products is the reduction of laundering bed linens and clothing.

Table 6 lists costs of different management practices using disposable and reusable products and based on five changes per 24 hours. With reusable products the cost per use depends upon the number of products needed and the number of times the product can be washed. The number of products needed depends upon a) the number needed each day, b) how often laundry is done, and c) and the number of times the product can be washed and worn. The number of washings per product as estimated by the manufacturer varies greatly.

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Table 5. Estimated costs of children's disposable diapers

		Diaper changes per day
Estimate of weeks by diaper size	Unit Cost	5.4	7	9
Birth to 3 months of age: 13 weeks, size small	$.15	$73.71	$95.55	$122.85
...to 12 months of age: 39 weeks, size medium	$.20	$294.84	$382.20	$491.40
...to 24 months of age: 52 weeks, size large	$.28	$550.37	$713.44	$917.28
...to 30 months of age: 26 weeks, size extra-large	$.32	$314.50	$407.68	$524.16

Environmental Issues

It is difficult to determine the precise environmental costs of diapers or of incontinence products; there are many trade-offs. Various national studies that have attempted to determine the environmental costs of infant diapers have come out with widely different findings, conclusions, and recommendations. The variability of these studies may be due to different definitions, assumptions, methodologies, numerical values used, and perspectives of the researchers.

Any fair discussion of environmental costs must consider the total life cycle including the use of energy, the amount and specific type of exposure to chemicals, risk or reduction of risk to humans and other organisms, the source and fate of all inputs and outputs including water, soil, air, metals, and other natural resources, and any synergistic effects of individual factors. It is clear that our current understanding of these issues needs to be improved (Diaper Manufacturers Group n.d.; Franklin Associates, Ltd. 1990; Lehrburger 1988; Lehrburger et al. 1991; Little 1990; Samuelson 1990).

One environmental issue relates to disposal. Disposables are safe for disposal by landfill, incineration, or composting when these waste management options are carried out in compliance with local, state and federal rules. 3 Lehrburger (1988) found that disposable diapers accounted for 2 percent of household waste by weight. A preliminary Minnesota Pollution Control Agency report on the composition of municipal solid waste (MSW) in Minnesota in 1990 indicated that approximately 2 percent of the MSW was classified as disposable diapers. While no exact measurements were conducted, staff working on this project were surprised to find a substantial portion of this total was incontinence products for adults. As the proportion of elderly in the population grows, the proportion of disposable products for adults is likely to increase. The U.S. Environmental Protection Agency in 1990 estimated that up to 2 percent of MSW was made up by disposal diapers. Rathje (1991) found that disposable diapers account for 0.8"/, of the total garbage contained in landfills.

As landfill space becomes scarce and more expensive due to government regulation, many people have suggested that we look at ways to minimize solid waste generation, including a return to cloth diapers, because disposible diapers generate 70 to 100 times more solid waste than do washable diapers. Another way to reduce the amount of solid waste is to select the smallest appropriate moisture-absorbing product-for example, a small drip collector instead of a full brief.

Cloth products require laundering, and some families do not have access to laundering equipment at home. Some families may have difficulty finding transportation in order to use public laundry facilities. Most commercial diaper services are located in urban areas. Furthermore, while the Minnesota Department of Human Services allows the use of cloth diapers in day care, most day care centers require disposables. The problem is not limited to families with infants; many incontinent adults also depend on disposable products.

Lehrburger (1989) and others have suggested that disposable diapers may represent a health risk at landfill sites. Authorities agree that feces from disposables should be emptied into the toilet, but landfill studies have proved that it seldom is done. It has not been shown that diaper wastes represent a significant health hazard in landfills (Lyman 1990).

The environmental costs of disposal are influenced by a product's biodegradability and recyclability. Most disposable diapers are made with a polypropylene liner and polyethylene backing (plastics); manufacturers say that they are 70 percent biodegradable (whether or not scientifically proven biodegradable plastics are used) because most of the product is cellulose. Industry-sponsored research is currently underway to determine if it is economically feasible to recycle disposable diapers.

Some businesses operate disposable diaper services that either recycle the plastic or compost the paper fiber. Some manufacturers have developed disposable diapers they claim to be "more" biodegradable, or biodegradable. However, without state and/or national definitions and standards for testing and measuring the biodegradability of diapers (especially of the plastic films and adhesives), these claims may simply be product marketing and nothing more. For a more detailed discussion on measuring the biodegradability of plastic films in soils, see Barak et a1. (1991).

The primary environmental cost of cloth products lies in laundering. Each full (extra-large) load of home-laundered diapers uses about 45 to 50 gallons of water, half of which must be heated and all of which is treated as wastewater. Front-loading washers use about half the amount of water used by top-loading washers. Households using a private sewage system need to plan for the additional wastewater load. Detergents and bleaches also can contribute to environmental degradation.

The creation of diaper products also has environmental costs. The vast majority of cloth diapers are made from cotton, a renewable resource. The production of cotton in the United States involves the use of large amounts of pesticides on a per-acre basis relative to wheat, soybeans, oats, or trees. Cotton production also uses a large amount of expensive and highly valued irrigation water. The fertilizer and energy inputs to produce a cotton crop also are relatively high compared to many other crops. Cotton production also can cause high rates of soil erosion in some areas.

Energy, transportation, chemicals, equipment, and labor are required to manufacture, distribute, launder, and eventually dispose of cotton cloth diapers. However, a single cotton cloth diaper can be reused a minimum of 75 times as compared to a disposable diaper that can be used once.

Some cloth diapers are made from fibers other than cotton, including wool, rayon, polypropylene, and nylon. Sometimes more than one type of fiber is used. Cloth diapers not made from cotton may have different total life cycle environmental costs than do cotton cloth diapers. Cotton diapers used with throw-away liners or disposable water-absorbent packets also may have different environmental costs.

Disposable diapers generally are made up of 70 percent paper fiber and 30 percent synthetic materials (primarily plastics). The paper fiber comes from trees, a renewable resource. In general, tree production uses much less pesticide on a per-acre basis than does cotton production. The amounts of fertilizer and mechanical energy and labor inputs needed per acre to grow trees are also much less than are used to produce cotton. Trees do use large amounts of water to grow, but they also give off large amounts of water back to the water cycle and rarely use expensive irrigation water. Tree production can cause high rates of soil erosion in some areas.

Energy, transportation, chemicals, equipment, and labor are required to manufacture paper fiber and produce, distribute, and dispose of the disposable diapers. The production of paper requires large amounts of water, energy, and chemicals. Some types of paper fiber can be recycled into disposable diapers.

Both tree and cotton production have a tendency to reduce diversity of plants and animals over time on the land where they are grown. The synthetic component of disposable diapers comes from petroleum, a nonrenewable resource. When disposable diapers are incinerated the energy value is recovered; when landfilled, they act as a storage sink for carbon.

Lehrburger (1988; Lehrburger et al. 1991) suggests that national policies should provide economic incentives (increased profits and/or subsidies) for businesses that provide cloth diaper services. He also suggests that users of cloth reusable diapers and diaper services may need additional economic incentives. Others have proposed laws that would tax or ban the sale or use of disposable diapers as a means to reduce solid waste. With the ease of entry and exit and relatively low capital costs, it is difficult to accept the argument that there has been a market failure in providing diaper laundry services to the public. The additional cost of solid waste disposal from single-use diapers appears to be something that many U.S. consumers do in fact understand.

It is obvious from this discussion that there are many trade-offs including water quality vs. energy use, landfills vs. tree production, soil erosion of forest production vs. soil erosion of cotton production. There is no clear and simple answer as to which type of product has the lower total life cycle environmental cost. There is a honest disagreement as to the environmental costs involved with cloth and disposable products as well as how to define and measure them. More research is needed' to better define the relative environmental costs and benefits of the various products.

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Summary

In this publication we have described some of the infant diaper and incontinence product choices that are now available. There is no simple answer to which choice of product is best for you, your family, or your community. The choices you make depend on many different factors; some of these factors are complementary and some are trade-offs. Some factors are more or less important depending upon your specific situation. While time may be a critical factor for infant diapers, independence and self esteem may be critical factors for incontinence products. The evaluation of complex and interrelated alternatives is not easy. As responsible people we must not only consider the performance and price of a product, but its broad environmental, health, and social effects as well.

In accordance with the Americans with Disabilities Act, this material is available in alternative formats upon request. Please contact your University of Minnesota Extension office or the Extension Store at (800) 876-8636.