Kelley Baer,  B.S., IBCLC, LCCE,
Professional Liaison Leader for the Area of LLL New Mexico, USA 

Introduction
What are Forever Chemicals?
How did ‘Forever Chemicals’ become so prevalent in the environment?
How concerned should we be?
The future for ‘Forever Chemicals’
Exposure of children and infants
Human Milk and the transfer of ‘Forever Chemicals’
Contamination in Infant Formula
Conclusion

Introduction

Alarming headlines blare out the presence of ‘forever chemicals’ in human milk. We immediately wonder if it means we should not breastfeed at all! Rest assured that all major public health agencies continue to recommend breastfeeding, despite toxins in our environment. The only exception at this time is having had a suspected or known significant exposure. In this case a discussion with your healthcare provider is advised. Overall, experts agree the ways human milk develops, nurtures, and protects neurological, immunological, and endocrine systems are critical. These are far more important to a growing child than the risks of getting toxins through human milk. Please see the article, “Contaminants in Human Milk” for more information.

What are ‘forever chemicals’? 

‘Forever chemicals,’ better known as PFAS, are perfluoroalkyl and polyfluoroalkyl substances, of which there are over 4700! Two of the most studied and problematic PFAS are PFOA (perfluorooctanoic acid) and PFOS (perfluorooctanesulfanic acid). These have been heavily used for decades in industry and consumer products.^1,2,3,4 Let’s take a deep dive into ‘forever chemicals’ to understand how they earn that name.

PFAS are one category of many Persistent Organic Pollutants (POPs). POPs also include dioxin, polybrominated diphenyl ethers (PBDE), polychlorinated biphenyl (PCB), and bisphenol A (BPA). None are considered healthy for humans, but we have all been exposed to them in some way in our environments. POPs are considered organic because they are carbon-based. POPs are toxic and, according to the Stockholm Convention, can contribute to “cancer, allergies and hypersensitivity, damage to the central and peripheral nervous systems, reproductive disorders, and disruption of the immune system. Some POPs are also considered to be endocrine disrupters, which, by altering the hormonal system, can damage the reproductive and immune systems of exposed individuals as well as their offspring; they can also have developmental and carcinogenic effects.”⁵

What makes a PFAS molecular structure unique is that it combines a string of carbon atoms with fluorine, considered one of the strongest bonds in organic chemistry. This bond does not naturally break down or decay, contributing to its longevity in the environment and earning PFAS the name ‘forever chemicals’. A longer carbon chain increases the longevity of the substance, both in the environment and in humans.

Only in the last couple decades have we realized how persistent PFAS are in the environment and in our bodies. They do not readily break down into benign components, and so linger for years to decades. PFAS pollute the soil, water, and air, and bio-accumulate in plants and animals, including humans. Eating higher on the food chain (meats and fish vs plants) increases the human body burden of POPs, including PFAS. The United States Centers for Disease Control and Prevention (CDC) cited a study in which 97% of United States citizens tested had some level of PFAS in their system.⁷ Although PFAS chemicals originated in the United States, it doesn’t mean the issue is contained within US borders. Many other countries produced or used PFAS in industry. This resulted in areas of PFAS pollution across the globe, with resulting health concerns for citizens in those nations.^8,9,10,11

How did ‘Forever Chemicals’ become so prevalent in the environment?

PFAS were first developed in the 1930s and put into widespread production in the 1950s. PFAS were prized for creating impermeable surfaces and fostering stain resistance. The US-based company, 3M (then Minnesota Mining and Manufacturing), produced PFOS, used in the consumer product Scotchgard, and PFOA, which the US-based company, DuPont, used to make PTFE (polytetrafluoroethylene), the substance that made Teflon a non-stick surface.¹² PFAS have been widely used in non-stick cookware, water-repellent clothing, stain-resistant fabrics and carpets, some cosmetics, some firefighting foams, and products that resist grease, water, and oil.^7,13 The chemicals that made life easier have also increased our risk of inadvertent contamination.

In 1961, DuPont raised concerns within the company about toxicity in exposed workers, and in 1981, concerns were raised regarding occupationally exposed women. It wasn’t until 1998 that United States communities realized their water supplies had been compromised by PFAS-contaminated water or dump sites.^14,15 In 2009, the Stockholm Convention called upon manufacturing industries to eliminate the use of PFOS and in 2019 to eliminate PFOA, although many manufacturers and industries worked to eliminate them prior to those dates.^16.17

How concerned should we be?

If the majority of United States citizens have some level of PFAS in their bodies, how concerned should people be? The answer is no one really knows. An alarm has been raised, though, and research about PFAS is published nearly weekly.

Beside contamination through consumer products, how are we exposed to PFAS? First, people who work in industries that utilize PFAS have the highest blood levels of PFAS. Those that live near heavily polluted areas also tend to have high PFAS levels. Industries that used PFAS in their manufacturing processes often polluted the soil and waterways surrounding their plants.^18.19 Many of these bodies of water are used as municipal water supplies. PFAS have been known to travel far from the original site of release.²⁰ Some military bases used AFFF (aqueous film forming foam), one of the PFAS, to fight aircraft fuel fires. Runoff from these bases has contaminated civilian drinking water.^8,21,22,23 Dairies and farms have been polluted, as well, either by AFFF runoff or use of sludge as fertilizer. Sewage sludge is marketed in the United States as a biosolid for use on fields as a fertilizer, or packaged as fertilizer or compost for home use.^24,25 When tested, some dairies and farms were producing products with high levels of PFAS, some for decades, unbeknownst to the owners.^26,27,28 So, there are areas of known contamination and people in those areas should take precautions because they are at highest risk, but new areas continue to be identified. Unfortunately, there is presently no easy way to remediate contaminated areas.

Most areas of contamination contain older PFAS structures, often called ‘legacy’ PFAS, chemical structures with 8 or more carbon atoms. (PFOA and PFOS are both 8-carbon chain molecules.) PFOA and PFOS products were phased out in the United States in 2008-2009, with the exception of certain essential products that could not be replicated with smaller chain structures.²⁹ Legacy PFAS have been linked to “reproductive effects (decreased fertility or increased risk of high blood pressure/pre-eclampsia in pregnancy), developmental effects or delays in children (including low birthweight, accelerated puberty, bone variations, or behavioral changes), increased risk of some cancers (including prostate, kidney, and testicular cancers), reduced ability of the body’s immune system to fight infections (including reduced vaccine response), interference with the body’s natural hormones, increased cholesterol levels and/or risk of obesity.”³⁰ Studies suggest a link between PFAS and heart disease in women.³¹

The future of ‘Forever Chemicals’

Even in countries that have phased out legacy PFAS, imported products may still contain them. Too, manufacturers have sought to replace legacy PFAS with newer ‘novel’ or ‘alternative’ PFAS. The novel PFAS structures have shorter carbon chains, but still manifest concerning properties. Novel PFAS can also persist in the environment and travel further. There is increased uptake in the body (with less bioaccumulation).^{6,24,32,33,34} These novel forms of PFAS are often lumped under the term GenX. They can be found in:

• grease-resistant papers (e.g., fast food containers/wrappers, microwave popcorn bags, pizza boxes, candy wrappers); 
• stain resistance either incorporated into or as spray-on coating applied to carpets and upholstery in home and vehicle products; 
• water resistant clothing and footwear; 
• cleaning products; 
• personal care products (e.g., shampoo, dental floss, cosmetics such as nail polish and eye makeup); 
• paints, varnishes, ski wax and sealants.³⁵ 

Yes, items we use daily. 

The Agency of Toxic Substances and Disease Registry (ATSDR) in the United States cautions that adverse outcomes may be linked to PFAS exposure, but the mechanisms of action are not always clear. They state that additional research could help clarify levels and routes of exposure in the disease process.^3,24 Additionally, Blake and Fenton note that PFAS accumulates in (blood) serum, lungs, kidneys, liver, and brain, rather than in fatty (adipose) tissue as do other common environmental pollutants/POPs. They conclude that “the weight of evidence supporting these [adverse health] associations varies by both outcome and specific PFAS studied.” (pg4) They delve into this topic more in a section of their paper entitled “Challenges of Studying PFAS Related Human Health Effects” (pg6).⁸

Countries are working to determine and enforce water standards for PFAS. In January 2021, the Drinking Water Directive entered into force, with member states of the European Union having two years to implement the Directive into national legislation.^36,37 The Netherlands, Denmark, Germany, Norway, and Sweden are working on a proposal to ban all PFAS in Europe so that one PFAS substance cannot be replaced by another. That proposal is due to be submitted to the European Chemicals Agency (ECHA) in January 2023.³⁸ Although the Environmental Protection Agency (EPA) in the United States has set a suggested water standard for PFAS, it is not considered a federal regulatory standard and is therefore unenforceable. However, the EPA has released a plan of action to address PFAS, “PFAS Strategic Roadmap.”³⁹ It has plans to finalize PFAS/PFOS water standards by the end of 2023, and begin evaluating standards for other PFAS.³⁵ In the meantime, some individual states have developed and adopted their own water quality standards for PFAS.^8,40

Exposure of Children and Infants

Children and infants are a particularly vulnerable population in relation to PFAS exposure and body burden.²⁴ The EPA notes that as children are growing, they drink more water and eat more food per pound of body weight than adults. They also breathe more air for their size.  All of these can increase their exposure to PFAS. They also caution that children crawl on floors and put items in their mouths which can lead to a higher risk due to PFAS in carpets, upholstery, household dust, toys, and cleaning products.²⁶

We know children are exposed after birth, but they are also exposed to PFAS – and other POPs that most of us don’t know we have in our bodies – in utero. PFAS are known to cross the placenta, affecting the developing infant in women with a high body burden.^8,24 PFAS can also affect the function of the placenta, posing a higher risk of elevated maternal blood pressure and pre-eclampsia, although the mechanism is not well understood. Placental dysfunction may also contribute to chronic disease of the child in adulthood.⁸ Also, concerns regarding mammary gland development arise with childhood and pubertal exposure to POPs, including PFOA, in both men and women. These exposures may increase someone’s risk of cancers and impaired lactation.⁴¹

Human Milk and the transfer of ‘Forever Chemicals’

Human milk is another means of PFAS transfer from mother to child. However, pregnancy is thought to be a means of greater transfer.³⁸ Currently, no guidance values exist for levels of PFAS in human milk in the United States or Canada.⁴² If a parent has a known high body burden of any toxin, they should discuss their feeding options with their child’s pediatrician.

Transfer of PFAS through human milk is thought to be about 1% of maternal serum levels. However, lactational transfer of POPs stored in fat tissue, such as PCBs, PBDEs, and organochlorine pesticides, occurs at a higher rate. These compounds are also more likely to build up in human milk.²⁴ Good news: the level of legacy PFAS is decreasing in human milk as use and manufacturing of these substances has decreased. However, the level of novel PFAS is increasing.¹³ Hence, infants are exposed through both the placenta and through human milk. They continue to be exposed as they wean and begin eating solid foods.

Contamination in Infant Formula

PFAS contamination has also been found in cow’s milk and baby milk substitutes (e.g., infant formula).⁴³ Chemical studies of infant formulas in the United States and Canada are not readily available.³⁸ Formula companies must adhere to good manufacturing practices and quality control. However, not all countries require Hazard Analysis and Critical Control Point (HACCP) quality standards for infant formula. These standards are mandatory/required in most other aspects of the food industry.⁴⁴

An overview of literature on contaminants in human milk and infant outcomes by LaKind et al. concluded that even with higher exposure to PCBs, breastfed infants fared better than formula-fed infants in terms of neurological development, physical growth, and immunological status.³⁹ Preparation of powdered formula with contaminated water in affected communities is a concern.³⁸ In a community with a verified contaminated water supply, families should drink bottled water and formula should be prepared with bottled water.

In 2022, Dr. Brittany Trang and Dr. William Dichtel, chemists at Northwestern University, explored methods to break the carbon-fluorine bond in PFAS with the intent to remediate PFAS contamination. They fine-tuned their findings by adding scientists from the University of California and China to their team. Together they have found a safe and inexpensive means of removing PFAS from water and soil. Although their method is not yet ready for wide use, it holds great promise.^45,46,47

Conclusion

Environmental pollution is a problem that affects everyone, including families and their babies.

What can we do to protect ourselves? We can educate ourselves on PFAS in our everyday environment. See ‘Additional Resources’ for ideas to limit PFAS exposure.

The ATSDR states, “The benefits of breastfeeding outweigh any potential risks of PFAS exposure through breastmilk.”⁴⁴ The American Academy of Pediatrics (AAP) states that, “although a number of environmental pollutants readily pass to the infant through human milk, the advantages of breastfeeding continue to greatly outweigh the potential risks in nearly every circumstance.”⁴⁸ The World Health Organization (WHO) agrees with these statements, as well: “Based on our present knowledge, we conclude that the benefits of breastfeeding far outweigh the toxicological disadvantages that are associated with certain POPs,”⁴⁹ and “If potential adverse effects are balanced against positive health aspects for (breastfed) infants, the advantages of breastfeeding far outweigh the possible disadvantages.”⁵⁰

You can remain confident that the superior qualities of human milk to build and protect brains and immune systems hold lasting benefit to your baby, as does the act of lactating to you, the parent!^{39,4051,52,53} For these reasons, all public health agencies and organizations continue to recommend human milk as the physiological and safest source of infant food.

Additional Resources

Tips for Reducing PFAS Exposure:

Healthy Children, PFAS: Limiting Children’s Exposure to ‘Forever Chemicals’, September 8, 2021, https://www.healthychildren.org/English/safety-prevention/all-around/Pages/Limiting-Childrens-Exposure-to-Forever-Chemicals.aspx [accessed April 24, 2022]

Natural Resources Defense Council, “Forever Chemicals” Called PFAS Show Up in Your Food, Clothes, and Home, April 6, 2022, https://www.nrdc.org/stories/forever-chemicals-called-pfas-show-your-food-clothes-and-home [accessed April 24, 2022]

Environmental Working Group, EWG’s Guide to Avoiding PFAS Chemicals, 2018, https://static.ewg.org/ewg-tip-sheets/EWG-AvoidingPFCs.pdf [accessed April 24, 2022]

United States Environmental Protection Agency, Meaningful and Achievable Steps You Can Take to Reduce Your Risk: Limiting Your Exposure to PFAS Can Help Protect Your Health, 

General:

United States Centers for Disease Control and Prevention, Factsheets: National Biomonitoring Chemical Factsheets, page last reviewed April 7, 2017, https://www.cdc.gov/biomonitoring/chemical_factsheets.html [accessed April 25, 2022]

Chemical and Engineering News, A Guide to the PFAS Found in our Environment, https://cen.acs.org/sections/pfas.html [accessed April 25, 2022]

European Environmental Agency, PFAS Pollution is Widespread in Europe, but Risks Poorly Understood, December 12, 2019, https://www.eea.europa.eu/highlights/pfas-pollution-is-widespread-in [accessed April 24, 2022]

European Chemicals Agency, Perfluroalkyls Chemicals, https://echa.europa.eu/hot-topics/perfluoroalkyl-chemicals-pfas [accessed April 25, 2022] 

EFSA Panel on Contaminants in the Food Chain (EFSA CONTAM Panel), (European Food Safety Authority) Schrenk D, Bignami M, et al. Risk to human health related to the presence of perfluoroalkyl substances in food. EFSA J. 2020;18(9):e06223. Published 2020 Sep 17. doi:10.2903/j.efsa.2020.6223, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7507523/ [accessed April 27, 2002]

Environmental Working Group, Human Toxome Project, Perfluorochemicals (PFCs) [listed in right hand column], https://www.ewg.org/sites/humantoxome/chemicals/chemical_classes.php?class=Perfluorochemicals+%28PFCs%29 

United States Food and Drug Administration, Per- and Polyfluoroalkyl Substances (PFAS) in Cosmetics, February 25, 2022 https://www.fda.gov/cosmetics/cosmetic-ingredients/and-polyfluoroalkyl-substances-pfas-cosmetics [accessed April 24, 2022]

Pediatric Environmental Health Safety Units (PEHSU) (United States), https://www.pehsu.net/

Drinking Water Standards:

Australian Government, PFAS, https://www.pfas.gov.au/government-action [accessed April 27, 2022]

Australian PFAS Chemical Map: https://pfas.australianmap.net/ [accessed April 24, 2022]

Canada, Government of Canada, Water Talk: Perfluoroalklylated Substances in Drinking Water, April 2019, https://www.canada.ca/en/services/health/publications/healthy-living/water-talk-drinking-water-screening-values-perfluoroalkylated-substances.html [accessed April 24, 2022]

European Commission, Commission Staff Working Document, Poly- and Perfluoroalkyl Substances (PFAS): Chemicals Strategy for Sustainability Towards a Toxic Free Environment, October 14, 2020, https://ec.europa.eu/environment/pdf/chemicals/2020/10/SWD_PFAS.pdf [accessed April 27, 2022]

Accelerating Research and Policy on PFAS in India, Environ Epidemiol, April 2022, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9005244/ [accessed April 25, 2022]

United States Environmental Protection Agency, EPA PFAS Action Plan: Program Update, February 2020, https://www.epa.gov/sites/default/files/2020-01/documents/pfas_action_plan_feb2020.pdf

United States Environmental Protection Agency, Drinking Water Health Advisories for PFOA and PFOS, https://www.epa.gov/sdwa/drinking-water-health-advisories-pfoa-and-pfos, Last updated July 12, 2022 [accessed July 13, 2022]

Environmental Working Group, PFAS Contamination in the US: Interactive Map, https://www.ewg.org/interactive-maps/pfas_contamination/ [accessed April 24, 2022]

PFAS Toxicology: What is Driving the Variation in Drinking Water Standards?, White Paper, 2019, https://portal.ct.gov/-/media/DEEP/PFASTaskForce/HHCBarlowBoydKempHoppeParr2019PFASToxicologypdf.pdf [accessed April 23, 2022]

REFERENCES

1. United States Centers for Disease Control and Prevention, Per- and Polyfluorinated Substances (PFAS) Fact Sheet, page last reviewed February 2, 2022, https://www.cdc.gov/biomonitoring/PFAS_FactSheet.html, [accessed April 27, 2022]

2. United States Centers for Disease Control and Prevention, Perfluorooctanoic Acid (PFOA) Fact Sheet, page last reviewed April 7, 2017, https://www.cdc.gov/biomonitoring/PFOA_FactSheet.html [accessed April 27, 2022]

3. Agency for Toxic Substances and Disease Registry, United States Centers for Disease Control and Prevention, Per- and Polyfluoroalkyl Substances and Your Heath: What are the Health Effects of PFAS?, page last reviewed June 24, 2020, https://www.atsdr.cdc.gov/pfas/health-effects/index.html [accessed April 27, 2022]

4. Agency for Toxic Substances and Disease Registry, United States Centers for Disease Control and Prevention, Per- and Polyfluoroalkyl Substances and Your Heath: PFAS in the U.S. Population, page last reviewed June 24, 2020, https://www.atsdr.cdc.gov/pfas/health-effects/us-population.html [accessed April 27, 2022]

5. United Nations Environment Programme, Stockholm Convention, What Are POPs?, http://chm.pops.int/TheConvention/ThePOPs/tabid/673/Default.aspx [accessed April 27, 2022]

6. Chemical and Engineering News, A Guide to the PFAS Found in Our Environment, https://cen.acs.org/sections/pfas.html [accessed April 27, 2022] 

7. National Institutes of Health (United States), National Institute of Environmental Health Sciences, Perfluoroalkyl and Polyfluoroalkyl Substances (PFAS), last reviewed March 7, 2022, https://www.niehs.nih.gov/health/topics/agents/pfc/index.cfm, [accessed May 11, 2022]

8. Mastrantonio, M., Bai, E., Uccelli, R., Cordiano, V., Screpanti, A., & Crosignani, P. (2018). Drinking water contamination from perfluoroalkyl substances (PFAS): an ecological mortality study in the Veneto Region, Italy. European Journal of Public Health, 28(1), 180-185. https://doi.org/10.1093/eurpub/ckx066, https://academic.oup.com/eurpub/article/28/1/180/3852033 [accessed October 10, 2022]

9. Zuzelo P. R. (2020). Water Worries: Quick Review of PFAS Contamination as a Health Threat. Holistic nursing practice, 34(2), 132–134. https://doi.org/10.1097/HNP.0000000000000368, https://pubmed.ncbi.nlm.nih.gov/32049699/ [accessed October 10, 2022)

10. Bonato M, Corrà F, Bellio M, Guidolin L, Tallandini L, Irato P, Santovito G. PFAS Environmental Pollution and Antioxidant Responses: An Overview of the Impact on Human Field. International Journal of Environmental Research and Public Health. 2020; 17(21):8020. https://doi.org/10.3390/ijerph17218020, https://www.mdpi.com/1660-4601/17/21/8020, [accessed October 10, 2022]

11. Yiyi Xu,Tony Fletcher,Daniela Pineda,Christian H. Lindh,Carina Nilsson,Anders Glynn,Carolina Vogs,Karin Norström,Karl Lilja,Kristina Jakobsson,and Ying Li, Serum Half-Lives for Short- and Long-Chain Perfluoroalkyl Acids after Ceasing Exposure from Drinking Water Contaminated by Firefighting Foam, Environmental Health Perspectives (2020) 128:7 CID: 077004 https://doi.org/10.1289/EHP6785, https://ehp.niehs.nih.gov/doi/10.1289/EHP6785 [accessed October 10, 2022]

12. 3M, PFAS History, https://www.3m.com/3M/en_US/pfas-stewardship-us/pfas-history/ [accessed April 27, 2022]

13. Agency for Toxic Substances and Disease Registry, United States Centers for Disease Control and Prevention, page last reviewed November 18, 2021, https://www.atsdr.cdc.gov/pfas/health-effects/overview.html [accessed April 27, 2022]

14. Business and Human Rights Resource Centre, DuPont Lawsuits (Re: PFOA Pollution in USA), https://www.business-humanrights.org/en/latest-news/dupont-lawsuits-re-pfoa-pollution-in-usa/ [accessed May 11, 2022] 

15. PFAS Project Lab, Northeastern University (United States), Parkersburg, West Virginia, https://pfasproject.com/parkersburg-west-virginia/ [accessed May 11, 2022]

16. United Nations Environment Programme, Stockholm Convention, PFOS, It’s Salts and PFOSF, http://chm.pops.int/Implementation/IndustrialPOPs/PFOS/Overview/tabid/5221/Default.aspx [accessed April 27, 2022]

17. Zheng G, Schreder E, Dempsey JC, Uding N, Chu V, Andres G, Sathyanarayana S, Salamova A. Per- and Polyfluoroalkyl Substances (PFAS) in Breast Milk: Concerning Trends for Current-Use PFAS. Environ Sci Technol. 2021 Jun 1;55(11):7510-7520. doi: 10.1021/acs.est.0c06978. Epub 2021 May 13. PMID: 33982557. https://pubmed.ncbi.nlm.nih.gov/33982557/ [accessed April 18, 2022]

18. Bevin E. Blake, Suzanne E. Fenton, Early life exposure to per- and polyfluoroalkyl substances (PFAS) and latent health outcomes: A review including the placenta as a target tissue and possible driver of peri- and postnatal effects, Toxicology, Volume 443, October 2020, 152565, ISSN 0300-483X, https://doi.org/10.1016/j.tox.2020.152565  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7530144/pdf/nihms-1627933.pdf [accessed April 27, 2022]

19. Banzhaf, S., Filipovic, M., Lewis, J. et al. A review of contamination of surface-, ground-, and drinking water in Sweden by perfluoroalkyl and polyfluoroalkyl substances (PFASs). Ambio 46, 335–346 (2017). https://doi.org/10.1007/s13280-016-0848-8, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5347527/ [accessed May 11, 2022]

20. National Conference of State Legislatures (United States), Per- and Polyfluoroalkyl (PFAS): State Legislation and Federal Action, page dated January 25, 2021, https://www.ncsl.org/research/environment-and-natural-resources/per-and-polyfluoroalkyl-substances-pfas-state-laws.aspx [accessed May 11, 2022]

21. Environmental Working Group, EPA Data Show Almost 900 ‘Forever Chemical’ Foam Releases, Many Into Local Waterways, March 11, 2022, https://www.ewg.org/news-insights/news/2022/03/epa-data-show-almost-900-forever-chemical-foam-releases-many-local [accessed April 27, 2022]

22. United States Department of Defense, DOD News, DOD’s PFAS Public Outreach Focuses on Cleanup Progress, PFAS-Free Firefighting Solutions, Officials Say, October 21, 2021, https://www.defense.gov/News/News-Stories/Article/Article/2818535/dods-pfas-public-outreach-focuses-on-cleanup-progress-pfas-free-firefighting-so/ [accessed April 27, 2022]

23. European Commission, Commission Staff Working Document, Poly- and Perfluoroalkyl Substances (PFAS): Chemicals Strategy for Sustainability Towards a Toxic Free Environment, October 14, 2020, https://ec.europa.eu/environment/pdf/chemicals/2020/10/SWD_PFAS.pdf [accessed April 27, 2022]

24. The Guardian, ‘Forever Chemicals’ Found in Home Fertilizer Made from Sewage Sludge, May 28, 2021, https://www.theguardian.com/environment/2021/may/28/home-fertilizer-toxic-pfas-forever-chemicals-sewage-sludge,[accessed May 11, 2022]

25. Sierra Club, Sludge in the Garden: Toxic PFAS in Home Fertilizers Made From Sewage Sludge, 2021, https://www.sierraclub.org/sludge-garden-toxic-pfas-home-fertilizers-made-sewage-sludge [accessed May 11, 2022] 

26.  Institute for Agriculture and Trade Policy (United States), With a Second Farm Shuttered Due to Massive PFAS Contamination, Maine Legislators Weigh Easing Access to the Courts, April 30, 2020, https://www.iatp.org/blog/202007/second-farm-shuttered-due-massive-pfas-contamination-maine-legislators-weigh-easing [accessed April 27, 2022]

27. ABC News 4 (United States), Military Warns Farmers Nationwide About PFAS Contamination That Threatens Their Livelihood, August 5, 2021, https://abcnews4.com/news/spotlight-on-america/military-warns-farmers-nationwide-about-pfas-contamination-that-threatens-their-livelihood [accessed April 27, 2022]

28. Institute for Agriculture and Trade Policy (United States), Forever Chemicals and Agriculture Case Study: Maine Accelerates Across-the-Board Action to Address PFAS Chemicals Harming Farmers and Rural Communities, November 9, 2021, https://www.iatp.org/documents/forever-chemicals-and-agriculture-case-study [accessed April 24, 2002]

29. PFHxS (potassium perfluorohexane-1-sodium), however, has a 6-carbon chain. It is often grouped with legacy PFAS due to its longevity (an approximately 7 year half life, according to the Environmental Working Group, , Human Toxome Project, Perfluorochemicals (PFCs)) [listed in right hand column], https://www.ewg.org/sites/humantoxome/chemicals/chemical_classes.php?class=Perfluorochemicals+%28PFCs%29 [accessed April 27, 2022]

30. United States Environmental Protection Agency, Our Current Understanding of the Human Health and Environmental Risks of PFAS, https://www.epa.gov/pfas/our-current-understanding-human-health-and-environmental-risks-pfas [accessed April 27, 2022]

31.  Ding, Karvonen-Gutierrez, et al, Per- and Polyfluoroalkyl Substances and Incident Hypertension in Multi-Racial/Ethnic Women: The Study of Women’s Health Across the Nation, Hypertension, https://doi.org/10.1161/HYPERTENSIONAHA.121.18809 Hypertension. 2022;79:1876–1886 https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.121.18809 [accessed July 13, 2022]

32. European Environment Agency, Emerging Chemical Risks in Europe – ‘PFAS’, published December 12, 2019, last modified March 2, 2022, https://www.eea.europa.eu/publications/emerging-chemical-risks-in-europe/emerging-chemical-risks-in-europe [accessed April 27, 2022]

33. European Commission, Commission Staff Working Document, Poly- and Perfluoroalkyl Substances (PFAS): Chemicals Strategy for Sustainability Towards a Toxic Free Environment, October 14, 2020, https://ec.europa.eu/environment/pdf/chemicals/2020/10/SWD_PFAS.pdf [accessed April 27, 2022]

34. Government of Canada, Per- and Polyfluoroalkyl Substances, Updated July 29, 2021, https://www.canada.ca/en/health-canada/services/chemical-substances/other-chemical-substances-interest/per-polyfluoroalkyl-substances.html [accessed April 27, 2022]

35. Bevin E. Blake, Suzanne E. Fenton, Early life exposure to per- and polyfluoroalkyl substances (PFAS) and latent health outcomes: A review including the placenta as a target tissue and possible driver of peri- and postnatal effects, Toxicology, Volume 443, October 2020, 152565, ISSN 0300-483X, https://doi.org/10.1016/j.tox.2020.152565
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7530144/pdf/nihms-1627933.pdf [accessed April 27, 2022]

36. United Nations Economic Commission for Europe, European Union Adopts New Drinking Water Directive: Protocol on Water and Health Has a Role to Play, January 27, 2021, https://unece.org/environment/news/european-union-adopts-new-drinking-water-directive-protocol-water-and-health-has [accessed April 27, 2022]

37. Organization for Economic Co-operation and Development, Portal on Per- and Polyfluoronated Chemicals: European Union, https://www.oecd.org/chemicalsafety/portal-perfluorinated-chemicals/countryinformation/european-union.htm [accessed April 24, 2022]

38. National Institute for Public Health and the Environment (The Netherlands), PFAS Restriction Proposal, https://www.rivm.nl/en/pfas/pfas-restriction-proposal [accessed April 24, 2022]

39. United States Environmental Protection Agency, PFAS Strategic Roadmap: EPA’s Commitment to Action, 2021-2024, https://www.epa.gov/system/files/documents/2021-10/pfas-roadmap_final-508.pdf [accessed April 27, 2022]

40. Langenbach B, Wilson M. Per- and Polyfluoroalkyl Substances (PFAS): Significance and Considerations within the Regulatory Framework of the USA. International Journal of Environmental Research and Public Health. 2021; 18(21):11142. https://doi.org/10.3390/ijerph182111142, October 2021, https://www.ncbi.nlm.nih.gov /pmc/articles/PMC8583519/ [accessed April 24, 2022

41. Ruthann A. Rudel, Suzanne E. Fenton, Janet M. Ackerman, Susan Y. Euling, and Susan L. Makris, August 2011, Environmental Exposures and Mammary Gland Development: State of the Science, Public Health Implications, and Research Recommendations, Environmental Health Perspectives 119:8 CID: https://doi.org/10.1289/ehp.1002864 https://ehp.niehs.nih.gov/doi/10.1289/ehp.1002864 [accessed April 24, 2022]

42. LaKind JS, Verner MA, Rogers RD, et al. Current Breast Milk PFAS Levels in the United States and Canada: After All This Time, Why Don’t We Know More?. Environ Health Perspect. February 2022;130(2):25002. doi:10.1289/EHP10359, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8865090/ [accessed April 27, 2022]

43. María Lorenzo, Marinella Farré, Cristina Blasco, Matthias Onghena, Yolanda Picó, Damià Barceló, Perfluoroalkyl substances in Breast milk, infant formula and baby food from Valencian Community (Spain), Environmental Nanotechnology, Monitoring & Management, Volume 6, 2016, Pages 108-115, ISSN 2215-1532,
https://doi.org/10.1016/j.enmm.2016.09.001. [accessed May 11, 2022]

44. Foodborne Infections and Intoxications, 5th ed, Chapter 15: Cronobacter Species, 2021, Hyein Jang, Gopal Gopinath, Flavia Negrete, Leah Weinstein, Angelika Lehner, Séamus Fanning, Ben D. Tall, https://www.sciencedirect.com/science/article/pii/B9780128195192000098, https://www.sciencedirect.com/topics/agricultural-and-biological-sciences/infant-formula [accessed May 13, 2022]

45. Trang, B., Li, Y., Xue, X. S., Ateia, M., Houk, K. N., & Dichtel, W. R. (2022). Low-temperature mineralization of perfluorocarboxylic acids. Science (New York, N.Y.), 377(6608), 839–845. https://doi.org/10.1126/science.abm8868, https://pubmed.ncbi.nlm.nih.gov/35981038/ [accessed October 10, 2022]

46. https://cen.acs.org/acs-news/acs-meeting-news/Maybe-PFAS-arent-sturdy-previously/100/i30 [accessed October 10, 2022]

47. https://news.northwestern.edu/stories/2022/08/forever-chemicals-destroyed-by-simple-new-method/ [accessed October 10, 2022]

48. American Academy of Pediatrics, Council on Environmental Health. Breast Milk. In: Etzel, RA, ed. Pediatric Environmental Health, 4th Edition; Itasca, IL: American Academy of Pediatrics; 2019. P. 238.)  as published at: https://www.atsdr.cdc.gov/pfas/health-effects/exposure.html [accessed April 27, 2022]

49. World Health Organization (Europe), Persistent Organic Pollutants in Human Milk, 2009, https://www.euro.who.int/__data/assets/pdf_file/0003/97032/4.3.-Persistant-Organic-Pollutantsm-EDITED_layouted_V2.pdf [accessed May 11, 2022]

50. van den Berg, M., Kypke, K., Kotz, A. et al. WHO/UNEP global surveys of PCDDs, PCDFs, PCBs and DDTs in human milk and benefit–risk evaluation of breastfeeding. Arch Toxicol 91, 83–96 (2017). https://doi.org/10.1007/s00204-016-1802-z, https://link.springer.com/article/10.1007/s00204-016-1802-z [accessed October 10, 2022]

51. Arnold C. Baby Steps Forward: Recommendations for Better Understanding Environmental Chemicals in Breast Milk and Infant Formula. Environ Health Perspect. 2019;127(6):64001. doi:10.1289/EHP4804 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6791535/ [accessed May 11, 2022]

52. Agency for Toxic Substances and Disease Registry, United States Centers for Disease Control and Prevention, page last reviewed November 19, 2021, https://www.atsdr.cdc.gov/pfas/health-effects/pfas-breastfeeding.html [accessed May 11, 2022]

53. Arthur I. Eidelman, MD; Richard J. Schanler, MD; Margreete Johnston, MD; Susan Landers, MD; Larry Noble, MD; Kinga Szucs, MD; Laura Viehmann, MD, The American Academy of Pediatrics Policy Statement: Breastfeeding and the Use of Human Milk, Pediatrics (2012) 129 (3): e827–e841. https://doi.org/10.1542/peds.2011-3552, https://publications.aap.org/pediatrics/article/129/3/e827/31785/Breastfeeding-and-the-Use-of-Human-Milk [accessed May 11, 2022]