title: The role of phthalate esters in autism development: A systematic review.
abstract: BACKGROUND
  Available evidence implicates environmental factors in the pathogenesis of autism spectrum disorders (ASD). However, the role of specific environmental chemicals such as phthalate esters that influence ASD risk remains elusive. This paper systematically reviews published evidences on association between prenatal and/or childhood exposure to phthalate and ASD.
  
  
  METHODS
  Studies pertaining to systematic literature search from Scopus, PubMed, PsycInfo and Web of Science prior to December 2015 were identified. The authors included studies which assessed the effect of exposure to phthalates on occurrence of ASD. This comprehensive bibliographic search identified five independent studies. Each eligible paper was summarized with respect to its methods and results with particular attention to study design and exposure assessment. Because of the heterogeneity in the type of included studies, different methods of assessing exposure to phthalates and the use of different statistics for summarizing the results, meta-analysis could not be used to combine the results of included studies.
  
  
  RESULTS
  The results of this systematic review have revealed the limited number of studies conducted and assessed phthalate exposure. Seven studies were regarded as relevant to the objectives of this review. Two of them did not measure phthalate exposure directly and did not result in quantitative results. Out of the five studies in which phthalate exposure was mainly measured by the examining biomarkers in biological samples, two were cohort studies (one with positive results and another one with not clear association). Among the three case control studies, two of them showed a significant relation between exposure to phthalate and ASD and the last case control study had negative results. Indeed, this case control studies showed a compromised phthalate metabolite glucuronidation pathway, as a probable explanation of mechanism of the relation between phthalate exposure and ASD.
  
  
  CONCLUSIONS
  This review reveals evidence showing a connection between exposure to phthalates and ASD. Nevertheless, further research is needed with appropriate attention to exposure assessment and relevant pre and post-natal cofounders.
authors: Center for Air Pollution Research (CAPR), Institute for Environmental Research (IER), Tehran University of Medical Sciences, Tehran, Iran.
authors: Maryam Zare
authors: MZ
authors: Jeddi
authors: Department of Biostatistics, School of Public Health, Iran University of Medical Sciences, Tehran, Iran.
authors: Leila
authors: L
authors: Janani
authors: Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran.
authors: Amir Hossein
authors: AH
authors: Memari
authors: Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran.
authors: Shahin
authors: S
authors: Akhondzadeh
authors: Center for Air Pollution Research (CAPR), Institute for Environmental Research (IER), Tehran University of Medical Sciences, Tehran, Iran; Department of Environmental Health Engineering, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. Electronic address: yunesian@tums.ac.ir.
authors: Masud
authors: M
authors: Yunesian
mesh_terms: D001321:Autistic Disorder / Q000139:chemically induced*; D004952:Esters / Q000633:toxicity*; D006801:Humans; D010795:Phthalic Acids / Q000633:toxicity*
chemical_list: D004952:Esters; D010795:Phthalic Acids; C032279:phthalic acid
keywords: Children with autism; Developmental disorder; Endocrine disruptors; Environmental risk factors; Phthalate esters