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The Navigation Guide—Evidence-Based Medicine Meets Environmental Health: Systematic Review of Human Evidence for PFOA Effects on Fetal Growth
Open accessAbstract
Background: The Navigation Guide methodology was developed to meet the need for a robust method of systematic and transparent research synthesis in environmental health science. We conducted a case study systematic review to support proof of concept of the method. Objective: We applied the Navigation Guide systematic review methodology to determine whether developmental exposure to perfluorooctanoic acid (PFOA) affects fetal growth in humans. Methods: We applied the first 3 steps of the Navigation Guide methodology to human epidemiological data: 1) specify the study question, 2) select the evidence, and 3) rate the quality and strength of the evidence. We developed a protocol, conducted a comprehensive search of the literature, and identified relevant studies using prespecified criteria. We evaluated each study for risk of bias and conducted meta-analyses on a subset of studies. We rated quality and strength of the entire body of human evidence. Results: We identified 18 human studies that met our inclusion criteria, and 9 of these were combined through meta-analysis. Through meta-analysis, we estimated that a 1-ng/mL increase in serum or plasma PFOA was associated with a –18.9 g (95% CI: –29.8, –7.9) difference in birth weight. We concluded that the risk of bias across studies was low, and we assigned a “moderate” quality rating to the overall body of human evidence. Conclusion: On the basis of this first application of the Navigation Guide systematic review methodology, we concluded that there is “sufficient” human evidence that developmental exposure to PFOA reduces fetal growth. Citation: Johnson PI, Sutton P, Atchley DS, Koustas E, Lam J, Sen S, Robinson KA, Axelrad DA, Woodruff TJ. 2014. The Navigation Guide—evidence-based medicine meets environmental health: systematic review of human evidence for PFOA effects on fetal growth. Environ Health Perspect 122:1028–1039; http://dx.doi.org/10.1289/ehp.1307893
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“such methods have only recently been developed and utilized in environmental health sciences [23–30].”
From A Systematic Review and Meta-Analysis of Multiple Airborne Pollutants and Autism Spectrum Disorder (2016) · cites this paper as [30]
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“This observation is consistent with our previous systematic reviews, [24, 27, 28, 30]”
From A Systematic Review and Meta-Analysis of Multiple Airborne Pollutants and Autism Spectrum Disorder (2016) · cites this paper as [30]
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“…volume 122 | number 10 | October 2014 1029 there have been inconsistent conclusions about the evidence of an association between PFOA and fetal growth (DeWitt et al. 2009; Hekster et al. 2003; Jensen and Leffers 2008; Kennedy et al. 2004; Kudo and Kawashima 2003; Lau et al. 2004, 2007; Lindstrom…”
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The GRADE approach and Bradford Hill's criteria for causation
Schünemann, H., Hill, S., Guyatt, G., Akl, E. A., & Ahmed, F. (2011) · Journal of Epidemiology and Community Health · doi:10.1136/jech.2010.119933 · Cited by 262
Animal Research: Reporting In Vivo Experiments: The ARRIVE Guidelines
Kilkenny, C., Browne, W., Cuthill, I. C., Emerson, M., & Altman, D. G. (2010) · The Journal of Gene Medicine · doi:10.1002/jgm.1473 · Cited by 256
Emergency medicine animal research: does use of randomization and blinding affect the results?
Bebarta, V., Luyten, D., & Heard, K. (2003) · Academic Emergency Medicine · doi:10.1111/j.1553-2712.2003.tb00056.x · Cited by 244
Kim, S., Choi, K., Ji, K., Seo, J., Kho, Y., Park, J., Kim, S., Park, S., Hwang, I., Jeon, J.-M., et al. (2011) · Environmental Science and Technology · doi:10.1021/es202408a.s001 · Cited by 243 · cited 1×
“The existence of unmeasured confounders will always be possible with observational studies, but we decided to not let this under mine our ability to make a statement about the available data.”
BackgroundWhite, S., Calafat, A., Kuklenyik, Z., Villanueva, L. R., Zehr, R. D., Helfant, L., Strynar, M., Lindstrom, A., Thibodeaux, J. R., Wood, C., et al. (2006) · Toxicological Sciences · doi:10.1093/toxsci/kfl177 · Cited by 229
Maisonet, M., Terrell, M. L., Mcgeehin, M., Christensen, K., Holmes, A. K., Calafat, A., & Marcus, M. (2012) · Environmental Health Perspectives · doi:10.1289/ehp.1003096 · Cited by 228 · cited 10×
“One exception was Maisonet et al. (2012) (see Supplemental Material, Table S13), for which we designated a higher risk of bias for fetal growth measures other than birth weight because of a large amount of missing data for outcomes other than birth weight in that study.”
BackgroundMethodInfluentialDeterminants of Fetal Exposure to Polyfluoroalkyl Compounds in Baltimore, Maryland
Apelberg, B. J., Goldman, L. R., Calafat, A. M., Herbstman, J. B., Kuklenyik, Z., Heidler, J., Needham, L. L., Halden, R. U., & Witter, F. R. (2007) · Environmental Science & Technology · doi:10.1021/es0700911 · Cited by 226 · cited 8×
“Study PFOA increase PFOA range (ng/mL) Covariates Apelberg et al. 2007 ln ng/mL 0.3–7.1 ga Apelberg et al. 2007 ln ng/mL 0.3–7.1 ga, ma, bmi, race, par, smk, sex, ht, wtg, dia, hyp Apelberg et al. 2007 25th to 75th percentile 1.2–2.1 ga Apelberg et al. 2007 25th to 75th percentile 1.2–2.1 ga, ma, bmi, race, par, smk,…”
BackgroundMethodInfluentialLam, J., Koustas, E., Sutton, P., Johnson, P. I., Atchley, D. S., Sen, S., Robinson, K. A., Axelrad, D. A., & Woodruff, T. J. (2014) · Environmental Health Perspectives · doi:10.1289/ehp.1307923 · Cited by 214 · cited 3×
“…of applying the Navigation Guide method ology to the non human evidence are presented in another review (Koustas et al. 2014), and the results of applying the Navigation Guide methodology to integrate the human and non human evidence streams are presented in a third review (Lam et al. 2014).”
BackgroundMethodInfluentialSelf-citationWolf, C. J., Fenton, S., Schmid, J., Calafat, A., Kuklenyik, Z., Bryant, X. A., Thibodeaux, J. R., Das, K., White, S., Lau, C., et al. (2006) · Toxicological Sciences · doi:10.1093/toxsci/kfl159 · Cited by 199
Perfluorinated Compounds in Umbilical Cord Blood and Adverse Birth Outcomes
Chen, M.-H., Ha, E., Wen, T.-W., Su, Y.-D., Lien, G., Chen, C.-Y., Chen, P.-C., & Hsieh, W. S. (2012) · PLoS ONE · doi:10.1371/journal.pone.0042474 · Cited by 191 · cited 11×
“These later publica tions (Chen et al. 2012; Maisonet et al. 2012; Whitworth et al. 2012) were included in our metaanalysis, showing consistent results and an overall reduction in birth weight associated with PFOA exposure.”
BackgroundMethodResultInfluentialThe reproductive toxicology of ammonium perfluorooctanoate (APFO) in the rat
Butenhoff, J. L., Kennedy, G. L., Frame, S. R., O’Connor, J. C., & York, R. G. (2004) · Toxicology · doi:10.1016/j.tox.2003.11.005 · Cited by 188
Hagenaars, A., Vergauwen, L., Coen, W. D., & Knapen, D. (2010) · Chemosphere · doi:10.1016/j.chemosphere.2010.10.076 · Cited by 188
Sawaya, G. F., Guirguis‐Blake, J., LeFevre, M. L., Harris, R., Petitti, D. B., & for the U.S. Preventive Services Task Force (2007) · Annals of Internal Medicine · doi:10.7326/0003-4819-147-12-200712180-00007 · Cited by 187 · cited 4×
“We used criteria and considerations used by IARC (2006), the U.S. Preventive Services Task Force (Sawaya et al. 2007), and the U.S. EPA (1991, 1996) for the type of evidence considered for each of these strength of evidence categories.”
BackgroundMethodInfluentialBoberg, J., Metzdorff, S., Wortziger, R., Axelstad, M., Brokken, L., Vinggaard, A., Dalgaard, M., & Nellemann, C. (2008) · Toxicology · doi:10.1016/j.tox.2008.05.020 · Cited by 185
Improving the translational hit of experimental treatments in multiple sclerosis
Vesterinen, H. M., Sena, E. S., ffrench-Constant, C., Williams, A., Chandran, S., & Macleod, M. R. (2010) · Multiple Sclerosis Journal · doi:10.1177/1352458510379612 · Cited by 182
Perfluorooctanoic Acid Exposure and Pregnancy Outcome in a Highly Exposed Community
Savitz, D. A., Stein, C. R., Bartell, S. M., Elston, B., Gong, J. F., Shin, H., & Wellenius, G. A. (2012) · Epidemiology · doi:10.1097/ede.0b013e31824cb93b · Cited by 177 · cited 13×
“…ga, bmi, par, smk Nolan et al. 2009 Low to mid exposure NA ga, ga2, ga3, ma, race, sex, SES Nolan et al. 2009 Low to high exposure NA ga, ga2, ga3, ma, race, sex, SES Savitz et al. 2012b, study II 25th to 75th IQR (ln PFOA) 1.92 ga, ma, par, edu, smk, exposyr, state Savitz et al. 2012b, study II…”
BackgroundMethodResultInfluentialFetal growth indicators and perfluorinated chemicals: a study in the Danish National Birth Cohort.
Fei, C.-Y., Mclaughlin, J., Tarone, R., & Olsen, J. (2008) · American Journal of Epidemiology · doi:10.1093/aje/kwn095 · Cited by 168 · cited 3×
“The Fei et al. study (2007) was the only study that was included in the meta-analysis and was assigned “high” risk of bias for “conflict of interest.”
BackgroundMethodKim, S., Lee, K. T., Kang, C. S., Tao, L., Kannan, K., Kim, K., Kim, C.-K., Lee, J. S., Park, P. S., Yoo, Y. W., et al. (2010) · Environmental Pollution · doi:10.1016/j.envpol.2010.09.008 · Cited by 161
Krauth, D., Woodruff, T. J., & Bero, L. A. (2013) · Environmental Health Perspectives · doi:10.1289/ehp.1206389 · Cited by 154 · cited 2×
“We also included the funding source and declared conflicts of interest as a potential source of bias based on empirical data from studies conducted on phar macological treatments that reported evidence of bias associated with funding source (Krauth et al. 2013; Lundh et al. 2012).”
MethodSelf-citationPrenatal Exposure to PFOS or PFOA Alters Motor Function in Mice in a Sex-Related Manner
Onishchenko, N., Fischer, C., Ibrahim, W. N. W., Negri, S., Spulber, S., Cottica, D., & Ceccatelli, S. (2011) · Neurotoxicity research · doi:10.1007/s12640-010-9200-4 · Cited by 152
Maternal exposure to perfluorinated acids and fetal growth
Hamm, M. P., Cherry, N. M., Chan, E., Martin, J. W., & Burstyn, I. (2010) · Journal of Exposure Science & Environmental Epidemiology · doi:10.1038/jes.2009.57 · Cited by 151 · cited 9×
“…None Hamm et al. 2010 ln ng/mL < LOD–18 ga, ma, race, grav, mwt, matht, smk, sex Hamm et al. 2010 ng/mL < LOD–18 ga, ma, race, grav, mwt, matht, smk, sex Hamm et al. 2010 1st to 2nd tertile (ng/mL) < LOD– < 1.1 to 1.1–2.1 ga, ma, race, grav, mwt, matht, smk, sex Hamm et al. 2010 1st to 3rd…”
BackgroundMethodResultInfluentialReporting of conflicts of interest in meta-analyses of trials of pharmacological treatments
Roseman, M. (2011) · JAMA · doi:10.1001/jama.2011.257 · Cited by 145
Developmental Origins of Health and Disease: List of contributors
Gluckman, P., & Hanson, M. (2006) · Cambridge University Press eBooks · doi:10.1017/cbo9780511544699 · Cited by 142
White, S., Stanko, J., Kato, K., Calafat, A., Hines, E., & Fenton, S. (2011) · Environmental Health Perspectives · doi:10.1289/ehp.1002741 · Cited by 138 · cited 1×
“…the evidence of an association between PFOA and fetal growth (DeWitt et al. 2009; Hekster et al. 2003; Jensen and Leffers 2008; Kennedy et al. 2004; Kudo and Kawashima 2003; Lau et al. 2004, 2007; Lindstrom et al. 2011; Olsen et al. 2009; Post et al. 2012; Steenland et al. 2010; White et al. 2011).”
BackgroundWoodruff, T. J., Sutton, P., & The Navigation Guide Work Group (2011) · Health Affairs · doi:10.1377/hlthaff.2010.1219 · Cited by 134
Self-citationThe effect of prenatal perfluorinated chemicals exposures on pediatric atopy
Wang, I., Hsieh, W., Chen, C., Fletcher, T., Lien, G., Chiang, H., Chiang, C., Wu, T.-N., & Chen, P. (2011) · Environmental Research · doi:10.1016/j.envres.2011.04.006 · Cited by 128 · cited 2×
“In addition, by contacting authors of one of the included studies (Wang et al. 2011), we were alerted to an additional study on the same cohort under review at the time (Chen et al. 2012) and were able to include that study in the metaanalysis.”
BackgroundSavitz, D. A., Stein, C. R., Elston, B., Wellenius, G. A., Bartell, S. M., Shin, H., Vieira, V. M., & Fletcher, T. (2012) · Environmental Health Perspectives · doi:10.1289/ehp.1104752 · Cited by 121 · cited 12×
“…ga, bmi, par, smk Nolan et al. 2009 Low to mid exposure NA ga, ga2, ga3, ma, race, sex, SES Nolan et al. 2009 Low to high exposure NA ga, ga2, ga3, ma, race, sex, SES Savitz et al. 2012b, study II 25th to 75th IQR (ln PFOA) 1.92 ga, ma, par, edu, smk, exposyr, state Savitz et al. 2012b, study II…”
BackgroundMethodResultInfluentialPerfluorinated compounds in relation to birth weight in the Norwegian Mother and Child Cohort Study.
Whitworth, K. W., Haug, L., Baird, D., Becher, G., Hoppin, J., Skjærven, R., Thomsen, C., Eggesbø, M., Travlos, G., Wilson, R., et al. (2012) · American Journal of Epidemiology · doi:10.1093/aje/kwr459 · Cited by 112 · cited 12×
“…2009 ng/mL ND–5.3 ma, ga Whitworth et al. 2012 ng/mL median (IQR) = 2.2(1.6–3.0) ga, ma, bmi, par Whitworth et al. 2012 1st to 2nd quartile < 1.65 to 1.65–2.24 ga, ma, bmi, par Whitworth et al. 2012 1st to 3rd quartile < 1.65 to 2.25–3.03 ga, ma, bmi, par Whitworth et al. 2012 1st to 4th…”
BackgroundResultInfluentialPerfluorooctanoate: Placental and lactational transport pharmacokinetics in rats.
Hinderliter, P., Mylchreest, E., Gannon, S. A., Butenhoff, J., & Kennedy, G. (2005) · Toxicology · doi:10.1016/j.tox.2005.03.010 · Cited by 101
Nolan, L. A., Nolan, J. M., Shofer, F., Rodway, N., & Emmett, E. (2008) · Reproductive Toxicology · doi:10.1016/j.reprotox.2008.11.001 · Cited by 96 · cited 1×
“Maternal age and gestational age may be correlated with PFOA exposure and fetal growth (Fei et al. 2007; Halldorsson et al. 2012; Ode et al. 2013).”
BackgroundDeterminants of maternal and fetal exposure and temporal trends of perfluorinated compounds
Ode, A., Rylander, L., Lindh, C. H., Källén, K., Jönsson, B., Gustafsson, P., Olofsson, P., Ivarsson, S. A., & Rignell‐Hydbom, A. (2013) · Environmental Science and Pollution Research · doi:10.1007/s11356-013-1573-5 · Cited by 90 · cited 1×
“Maternal age and gestational age may be correlated with PFOA exposure and fetal growth (Fei et al. 2007; Halldorsson et al. 2012; Ode et al. 2013).”
BackgroundWhite, S., Kato, K., Jia, L. T., Basden, B. J., Calafat, A., Hines, E., Stanko, J., Wolf, C. J., Abbott, B., & Fenton, S. (2008) · Reproductive Toxicology · doi:10.1016/j.reprotox.2008.11.054 · Cited by 88
Fenton, S., Reiner, J. L., Nakayama, S., Delinsky, A. D., Stanko, J., Hines, E., White, S., Lindstrom, A., Strynar, M., & Petropoulou, S.-S. E. (2009) · Reproductive Toxicology · doi:10.1016/j.reprotox.2009.02.012 · Cited by 80
Umbilical cord blood levels of perfluoroalkyl acids and polybrominated flame retardants
Arbuckle, T. E., Kubwabo, C., WALKER, M. C., Davis, K. A., Lalonde, K., Kosarac, I., Wen, S. W., & Arnold, D. L. (2012) · International Journal of Hygiene and Environmental Health · doi:10.1016/j.ijheh.2012.03.004 · Cited by 78
Perfluorooctanoic acid induces developmental cardiotoxicity in chicken embryos and hatchlings
Jiang, Q., Lust, R. M., Strynar, M. J., Dagnino, S., & DeWitt, J. C. (2012) · Toxicology · doi:10.1016/j.tox.2012.01.005 · Cited by 69
DEVELOPMENTAL ORIGINS OF HEALTH AND DISEASE
Gilbert-Barness, E. F. (2007) · Fetal and Pediatric Pathology · doi:10.1080/15513810701394736 · Cited by 68
Effects of perfluorooctanoic acid (PFOA) exposure to pregnant mice on reproduction.
Yahia, D., el-Nasser, M. A., Abedel-Latif, M., Tsukuba, C., Yoshida, M., Sato, I., & Tsuda, S. (2010) · Journal of Toxicological Sciences · doi:10.2131/jts.35.527 · Cited by 67
Beronius, A., Molander, L., Rudén, C., & Hanberg, A. (2014) · Journal of Applied Toxicology · doi:10.1002/jat.2991 · Cited by 64
Forest Plot Viewer: a new graphing tool.
Boyles, A., Harris, S. F., Rooney, A. A., & Thayer, K. (2011) · Epidemiology · doi:10.1097/ede.0b013e318225ba48 · Cited by 60
Spachmo, B., & Arukwe, A. (2011) · Aquatic Toxicology · doi:10.1016/j.aquatox.2011.07.018 · Cited by 59
Preclinical studies of human disease: Time to take methodological quality seriously
van der Worp, H. B., & Macleod, M. R. (2011) · Journal of Molecular and Cellular Cardiology · doi:10.1016/j.yjmcc.2011.04.008 · Cited by 58
Guest Editorial: Biomarkers of Perfluorinated Chemicals and Birth Weight
Savitz, D. (2007) · Environmental Health Perspectives · doi:10.1289/ehp.10923 · Cited by 50
Neurobehavioral Teratogenicity of Perfluorinated Alkyls in an Avian Model
Pinkas, A., Slotkin, T. A., Brick-Turin, Y., Van der Zee, E. A., & Yanai, J. (2010) · Neurotoxicology and Teratology · doi:10.1016/j.ntt.2009.11.004 · Cited by 48
Staples, R. E., Burgess, B. A., & Kerns, W. (1984) · Fundamental and Applied Toxicology · doi:10.1016/0272-0590(84)90200-8 · Cited by 44
O'Brien, J., Crump, D., Mundy, L. J., Chu, S.-G., McLaren, K., Vongphachan, V., Letcher, R., & Kennedy, S. (2009) · Toxicology Letters · doi:10.1016/j.toxlet.2009.07.004 · Cited by 43
Bellinger, D. (2012) · Neurotoxicology · doi:10.1016/j.neuro.2012.04.003 · Cited by 36
York, R. G., Kennedy, G. L., Olsen, G. W., & Butenhoff, J. L. (2010) · Toxicology · doi:10.1016/j.tox.2010.03.005 · Cited by 27
Evidence-based translational medicine.
Howells, D., & Macleod, M. (2013) · Stroke · doi:10.1161/strokeaha.113.000469 · Cited by 26
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Disturbance of perfluorooctanoic acid on development and behavior in Drosophila larvae
Wang, J.-S., Li, Y., Liu, Y., Zhang, H., & Dai, J. (2010) · Environmental Toxicology and Chemistry · doi:10.1002/etc.237 · Cited by 19
Are developmentally exposed C57BL/6 mice insensitive to suppression of TDAR by PFOA?
Hu, Q., Strynar, M., & DeWitt, J. (2010) · Journal of Immunotoxicology · doi:10.3109/1547691x.2010.520045 · Cited by 13
Flagged first, then by citations
20 of the 131 references couldn’t be matched to a known paper.
Research works printed but not linked: 2
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Sorted by citations
SYRCLE’s risk of bias tool for animal studies
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“The authors noted similarities in experimental studies (Johnson et al. 2014; Koustas et al. 2014) and concluded that there was “sufficient” human and corroborative toxicology evidence of a detrimental effect of PFOA on birth weight (Johnson et al. 2014; Koustas et al. 2014; Lam et al. 2014).”
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Risk to human health related to the presence of perfluoroalkyl substances in food
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Metadata
- Authors
- Johnson, P. I., Sutton, P., Atchley, D. S., Koustas, E., Lam, J., Sen, S., Robinson, K. A., Axelrad, D. A., & Woodruff, T. J.
- Affiliations
- University of California, San Francisco (US)
- Environmental Protection Agency (US)
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
- Johns Hopkins University (US)
- Corresponding author
- Johnson, Paula I.
- Venue
- Environmental Health Perspectives
- Publisher
- American Chemical Society (ACS)
- Published
- 2014-06-25
- Volume
- 122
- Issue
- 10
- Pages
- 1028-1039
- ISSN
- 0091-6765 (ISSN-L)
- 1552-9924
- PMC
- PMC4181929
- OpenAlex
- W4243002209
- Cited by
- 449
- References
- 131
- Citations by year
- 2026: 29 · 2025: 31 · 2024: 36 · 2023: 43 · 2022: 32 · 2021: 50 · 2020: 68 · 2019: 34 · 2018: 31 · 2017: 42 · 2016: 25 · 2015: 20 · 2014: 8
- FWCI
- 2.88
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- public-domain
- creativecommons.org/licenses/by/4.0/ (vor, 1283 d)
- Locations
- Environmental Health Perspectives (publishedVersion, public-domain)
- PubMed Central (publishedVersion, public-domain)
- eScholarship (California Digital Library) (submittedVersion)
- Funders
- U.S. Department of Energy
- U.S. Environmental Protection Agency (RD-83543301)
- New York Community Trust
- Heinz Endowments
- Johnson Family Foundation
- Rose Foundation for Communities and the Environment
- Kaiser Permanente
- Office of Research and Development
- Oak Ridge Institute for Science and Education
- University of California, San Francisco
- National Center For Environmental Assessment
- National Institute of Environmental Health Sciences (ES018135, P01ES022841, ES022841, P20ES018135)
- Topics
- Physical Sciences › Environmental Science › Environmental Chemistry › Per- and polyfluoroalkyl substances research
- Social Sciences › Decision Sciences › Statistics, Probability and Uncertainty › Meta-analysis and systematic reviews
- Physical Sciences › Environmental Science › Health, Toxicology and Mutagenesis › Health, Environment, Cognitive Aging
- Keywords
- perfluorooctanoic acid, fetal growth, birth weight, early life exposure, environmental health, risk of bias, perfluorinated compounds
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