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Full blood count normal reference values for adults in France

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Full blood count normal reference values for

adults in France
Xavier Troussard, Sylviane Vol, Edouard Cornet, et al.

J Clin Pathol published online October 29, 2013

doi: 10.1136/jclinpath-2013-201687

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JCP Online First, published on October 29, 2013 as 10.1136/jclinpath-2013-201687
Original article

Full blood count normal reference values

for adults in France
Xavier Troussard,1 Sylviane Vol,2 Edouard Cornet,1 Valérie Bardet,3
Jean-Paul Couaillac,4 Chantal Fossat,5 Jean-Charles Luce,2 Eric Maldonado,6
Virginie Siguret,7 Jean Tichet,2 Olivier Lantieri,2 Joël Corberand,8 for the
French-Speaking Cellular Hematology Group (Groupe Francophone d’Hématologie
Cellulaire, GFHC)

▸ Additional material is ABSTRACT accreditation procedures and hence to have recog-

published online only. To view
please visit the journal online
(http://dx.doi.org/10.1136/
jclinpath-2013-201687).
1 defined, after establishing preanalytical conditions, in a
Laboratoire d’Hématologie,
CHU Côte de Nacre, Caen
Cedex 9, France
2
3
IRSA, La Riche Cedex, France
Service d’Hématologie
Biologique, CHU Cochin-Port
Royal, Paris Cedex 14, France
4
Laboratoire Hémato-biologie,
CH Cahors, Cahors, France
5
Laboratoire d’Hématologie,
CHU Timone, Marseille Cedex
5, France
6
Marketing Hématologie,
Siemens Healthcare
Diagnostics, Saint Denis,
France
7
Service d’Hématologie
biologique, Hôpital Européen
Georges Pompidou, Paris,
France
8
Laboratoire d’Hématologie,
CHU Toulouse—Rangueil,
Toulouse Cedex 9, France
Correspondence to
Dr Xavier Troussard,
Laboratoire d’Hématologie,
CHU Côte de Nacre, Caen
14000, France;
troussard-x@chu-caen.fr
Received 16 April 2013
Revised 17 September 2013
Accepted 23 September 2013
To cite: Troussard X, Vol S,
Cornet E, et al. J Clin Pathol
Published Online First:
[please include Day Month
Year] doi:10.1136/jclinpath-
2013-201687
Aims To determine full blood count (FBC) normal
reference values for adults.
Methods FBC normal values for healthy adults were
population of 33 258 subjects, 19 612 men and 13 646
women. The values were established after excluding
from this population all people having conditions liable
to modify, directly or indirectly, FBC parameters.
Results Results for values of standard parameters are
provided in detail for each parameter, by sex and by age
group from 16 to 69 years of age. In addition, we
present FBC values from a population of 339 subjects
aged over 69 years with no comorbidities.
Conclusions These normal values are proposed for use
in everyday practice. They make it possible to distinguish,
without ambiguity, a normal situation from a
pathological situation. Moreover, they might be used
over all mainland France.
The full blood count (FBC) is the most frequently
requested laboratory test in France. The wealth of
information provided by this multiparameter ana-
lysis can notably suggest specific diagnoses and can
lead to discovery of a haematological disease in a
fortuitous and timely manner so that appropriate
clinical management can be instigated.
Requesting physicians lacking a solid haematology
background base their interpretation of an FBC on
the quantitative reference values provided by the
laboratory. In France, as a usual practice, patients
consult or receive, in most cases, the results of their
FBC, read the results by themselves and then
attempt to interpret them and to compare them
with the reference values given on the results sheet.
The quality of laboratory tests is constantly
improving. The technological development of ana-
lysers and control over the analytical phase reduce
the risk of having to question the accuracy of the
quantitative data of the FBC. Nevertheless, patients
present to haematologists after interpreting their
values as abnormal in comparison with the refer-
ence values given on their results sheet. There is no
need to carry out structured surveys to demonstrate
the very wide variability in the reference values
provided by laboratories in mainland France.
Clinical pathology is currently undergoing
change and restructuring and a regulatory require-
ment for all laboratories is to prove their
nised and validated reference values.
A group of experts from the French-Speaking
Cellular Hematology Group propose on the basis
of established methodological principles FBC
normal reference values for use by all clinical path-
ology laboratories in mainland France.
MATERIALS AND METHODS
Population
Data from 142 110 adult subjects, 63 729 men
(44.8%) and 78 381 women (55.2%), were ana-
lysed. All subjects were aged 16–69 years and had a
periodic health assessment (PHA) at the
Inter-Regional Health Institute (IRSA) between 1
January 2008 and 31 July 2010.
IRSA consists of 11 Prevention and Public Health
Centers (CPSP) located in the Central-West area of
France. The number of subjects from each CPSP
were: La Riche: 21 307 (15%), Hérouville-St-Clair:
20 981 (15%), St-Lô: 6747 (5%), Alençon: 11 605
(8%), Le Mans: 21 806 (15%), Angers: 19 812
(14%), Cholet: 7869 (5.5%), Saint Doulchard:
6217 (4.5%), Châteauroux: 10 789 (8%), Le
Havre: 6727 (5%) and Laval: 8250 (6%). French
legislation does not allow knowing the ethnicity of
patients. However, the regions covered by the study
are not known to be regions with a high percentage
of non-Caucasians.
In France, the PHA is a regulatory service gov-
erned by law and available to all people affiliated to
the general health insurance scheme, which covers
85% of the French population. The content of the
PHA is determined by a reference document under
the authority of the National Health Insurance
Fund (Caisse Nationale d’Assurance Maladie) with
input from medical experts. It is updated periodic-
ally and consists of three parts: (1) a self-
questionnaire (146 items) for the collection of
socioprofessional and family data, behaviours
notably diet habits, physical activity, habits of
smoking and alcohol, and the subject’s past and
present health status, (2) laboratory tests including
an FBC, lipids profile, a blood glucose measure-
ment, liver function tests, and a urinary dipstick
test for glucose, proteins, blood and acetone. Other
tests (ferritin, serology for hepatitis B and C) may
be added according to age, sex and context. HIV
serology can also be carried out on the patient’s
request during the medical visit and (3) a medical

Copyright
Troussard X, et al. JArticle
Clin Patholauthor (or
2013;0:1–4. their employer) 2013.
doi:10.1136/jclinpath-2013-201687 Produced by BMJ Publishing Group Ltd under licence. 1
 Original article

examination based on the preceding elements to establish a
summary of the subject’s health.
A total of 142 110 individuals were initially analysed of
whom 42 589 (30%) were in a situation of deprivation. The
target populations in precarious situations are all remote system
health people: lack of identification of referring physician,
homelessness, unemployed, recipients of minimum income or
assisted contracts. The score EPICES (Evaluation of insecurity
and Health Inequalities in Health Examination Centers) is based
on 11 questions to determine if a person is in a precarious situ-
ation.1 Given that the percentage of deprived individuals in the
French population is estimated at 13%, the initial population
was rectified in line with this criterion. A random number was
assigned to every precarious subject and 27 717 of them, the
ones with the n lowest random numbers, were excluded. After
rectification, the population consisted of 114 393 subjects,
including 51 636 men (45%), 62 757 women (55%), and
14 872 precarious subjects (13%).
In order to determine normal FBC values in healthy subjects,
81 135 subjects were excluded from our study because of cri-
teria liable to directly or indirectly modify FBC parameters.
Eighteen exclusion criteria were used (table 1), most commonly
‘medication use’ in 58 009 subjects (52.5%) or ‘follow-up for
disease’ in 23 150 subjects (21%). In the end, 33 258 subjects,
19 612 men (59%) and 13 646 women (41%), were used to
determine normal values in healthy adult subjects. Note that
our study does not allow excluding patients with iron deficiency
and/or thalassaemia/haemoglobinopathies.
The FBC was performed on an Advia 2120 analyser (Siemens
France Holding SAS, 9 boulevard Finot—93 527 Saint-Denis
Cedex 2, France) that was quality control tested three times per
week by Eurocell Diagnostics (EUROCELL Diagnostics, 27, rue
du Village de la Métairie—35131 Chartres de Bretagne, France)
using three samples (low, normal, high) with a monthly report
of results. Haematocrit on ADVIA 2120 is calculated. The result
comes from mean cell volume (MCV) (measure) and red blood
cell (RBC) (measure) with a cytometry flow technology. MCV
on ADVIA system is measured directly cell by cell after a specific
reaction used RBCs reagent. No impact of potential residual
plasma could be observed, as with a manual technology.
International units were used.2
Statistics
All analyses were carried out using Number Crunching
Statistical Software 2007. The age groups had a width of
10 years, with the exception of one 4-year group (16–19 years)
and four 5-year groups in women aged 40–59 years in order to
refine FBC changes associated with the menopause. FBC vari-
ables by age and sex were described with means and SDs as well
as by 23 percentiles, from the 1st to the 99th. The 2.5 and 97.5
percentiles were used to describe normal values. When establish-
ing the normal values, adjacent age groups were merged when
the statistical difference between them was non-significant.
Comparisons between age ranges and between sexes were made
using Kruskal–Wallis test.

RESULTS
Full blood count The selected population, with age and sex distribution, is shown
Blood samples from subjects in a fasting state were collected in table 2. It consists of 32 919 subjects, including 19 393 men
from the elbow crease between 07:00 and 10:30 into Sarstedt and 13 526 women, aged 16–69 years, and closely representa-
tubes with K3 EDTA. They reached the IRSA central laboratory tive of the population of mainland France. In addition, 339 sub-
in Tours in less than 5 h. This laboratory is ISO 9001 certified. jects aged 70–79 years, 219 men and 120 women, were also
analysed, giving a total of 33 258 subjects.
Results for the values of standard parameters used in everyday
practice for the interpretation of the FBC are provided for
Table 1 Exclusion criteria applied to the initial population of
every parameter, by sex and by age group, in the appendix
114 393 subjects, of whom 14 872 were in a situation of
section. The summary table (table 3) provides reference values
precariousness, to obtain the analysis reference population of
by sex with upper and lower limits for subjects aged
32 919 individuals
16–69 years. Given the fact that a high percentage (91.7%) of
Exclusion criteria Men (%) Women (%) Total (n) subjects aged 70–79 are not eligible in a reference population,
we present reference values for that healthy limited population
Taking medication 37.9 64.5 58 009
(339 subjects) with no known comorbidities in online supple-
Follow-up/treatment for disease 21.4 25.1 23 150
mentary appendix 1.
Asthma 11.1 10.9 10 446
Variation between different age groups was observed.
Regular cough 11.0 6.3 8730
Red cell parameters (see online supplementary appendix 2):
Blood in stools 7.8 6.5 7268
For haemoglobin, in the age group 16–69 years, the mean
Personal cardiovascular history 7.6 6.5 7120
Transfusion 3.9 7.5 5920
Polyps 7.2 5.2 5761
Blood donation less than 3 months ago 5.5 4.3 4958 Table 2 Age distribution of analysis population
Pathological bleeding 6.1 3265 Age group (years) Men Women Total
Diabetes 3.1 2.6 2663
Epilepsy 2.1 2.4 2119 16–19 1387 0901 2288
Tuberculosis 1.2 1.5 1257 20–29 3054 1370 4424
Follow-up for kidney failure 0.8 0.5 635 30–39 4258 2711 6969
Pregnancy 1.0 534 40–49 5146 1873 8951
Ulcerative colitis 0.7 0.6 590 50–54 3801 1932 7249
Crohn’s disease 0.2 0.3 255 55–59 1870
Colon cancer 0.3 0.2 232 60–64 1747 1578 3038
Population without exclusion criteria (%, n) 37.6% 21.6% 28.8% 65–69 1291
n=19 393 n=13 526 n=32 919 Total 19 393 13 526 32 919

2 Troussard X, et al. J Clin Pathol 2013;0:1–4. doi:10.1136/jclinpath-2013-201687

 Original article

Platelet parameters (see online supplementary appendix 3):

Table 3 Full blood count normal reference values defined by
For the platelet count, mean values in women are higher than
values comprised between the 2.5 and 97.5 percentiles
those in men. The values are, respectively, 269×109/L (171–
Men Women 397) in men and 394×109/L (186–440) in women ( p<10−6).
(years) Min–max (years) Min–max This difference is seen in all age groups analysed (p<10−6 for
Haematocrit (%) 16–69 39.2–48.6 16–44 34.4–43.9
each age group). For the mean platelet volume, the mean value
45–54 34.7–44.6 is 8.7 fL (7.4–10.8) in men and 8.8 fL (7.5–10.9) in women
55–69 35.9–44.6 (p<10−6).
Haemoglobin (g/L) 16–69 134–167 16–49 115–149 White cell parameters (see online supplementary appendix 4):
50–54 118–151 The values of white cell parameters are expressed in absolute
55–69 121–150
values (#) not percentages (%) (table 3). The mean value of
Red blood cells 16–29 4.53–5.79 16–29 4.01–5.19
leucocytes is 6.6×109/L (4.1–10.8) in men and 6.6×109/L
(1012/L) 30–59 4.38–5.65 30–49 3.93–5.09
60–69 4.28–5.57 50–69 3.99–5.12 (3.9–10.9) in women ( p=0.130). For neutrophils, the mean
MCV (fL) 16–19 78.0–91.9 16–19 75.7–92.7 value is 3.6×109/L (1.8–6.8) in men and 3.7×109/L (1.7–7.1)
20–39 79.6–94.0 20–29 74.7–94.2 in women ( p<10−6). For eosinophils, the mean value is
40–49 81.0–94.9 30–39 77.9–95.3 0.21×109/L (0.05–0.56) in men and 0.19×109/L (0.04–0.53) in
50–59 82.2–96.3 40–69 79.9–95.6 women ( p<10−6). For basophils, values are identical in men
60–69 82.1–97.0
and women: 0.04×109/L (0.00–0.09) ( p<10−6). For lympho-
MCH (pg/cell) 16–19 26.3–32.1 16–29 24.4–32.1
20–69 27.3–32.8 30–69 26.4–32.6
cytes, the mean value is 2.3×109/L (1.3–3.8) in men and
MCHC (g/L) 16–69 324–363 16–69 319–358
2.2×109/L (1.3–3.6) in women ( p<10−6). For monocytes, the
Leucocytes (109/L) 16–49 4.09–11.00 16–44 4.02–11.42
value is 0.43×109/L (0.23–0.74) in men and 0.38×109/L
50–59 4.06–10.46 45–49 4.01–11.02 (0.20–0.65) in women ( p<10−6).
60–69 4.05–9.92 50–54 3.78–9.70
55–69 3.78–9.42 DISCUSSION
Neutrophils (109/L) 16–49 1.780–6.946 16–44 1.750–7.500 The FBC is the most frequently requested laboratory test: it
50–59 1.915–6.634 45–49 1.812–7.154
guides later additional investigations essential for diagnosing
60–69 1.847–6.138 50–54 1.720–6.299
55–69 1.692–5.839 and monitoring the patient. It provides valuable information,
Eosinophils (109/L) 16–19 0.046–0.630 16–19 0.040–0.576 provided that it is possible to distinguish between a normal
20–29 0.048–0.593 20–49 0.041–0.549 situation and a pathological situation in a very diverse range
30–59 0.046–0.547 50–69 0.044–0.474 of conditions. Under French regulations, all public- and
60–69 0.052–0.576 private-sector laboratories must give normal reference ranges
Basophils (109/L) 16–39 0.000–0.097 16–19 0.000–0.081 on FBC results sheets. These values vary widely between
40–69 0.000–0.091 20–69 0.000–0.085
laboratories and are liable to lead to interpretation errors and
Lymphocytes (109/ 16–39 1.340–3.919 16–29 1.370–3.966
L) 40–69 1.241–3.617 30–69 1.240–3.561 also unnecessary worry in patients. As other tests, the results
Monocytes (109/L) 16–39 0.228–0.773 16–29 0.201–0.714 of FBC analyses could be dependent on the analytical phase.
40–69 0.233–0.725 30–49 0.205–0.663 Furthermore, technical advances in automation and the con-
50–69 0.192–0.608 tinual improvement of quality programmes also contribute to
Platelets (109/L) 16–59 172–398 16–54 185–445 the high homogeneity of the analytical phase of the FBC. The
60–69 161–393 55–69 187–420 auto-analyser we used could have impacted on the values
MPV (fL) 16–69 7.4–10.8 16–69 7.5–10.9 obtained, especially values from healthy subjects. If they do
Min, minimum, 2.5 percentiles; Max, maximum, 97.5 percentiles. exist, they are probably minor and non-significant with the
MCH, mean corpuscular haemoglobin; MCHC, mean cell haemoglobin concentration; proviso that all requirements of the quality programme are
MCV, mean cell volume; MPV, mean platelet volume.
respected ( preanalytical, internal and external quality
controls).
Mainland France, situated on the 45th North parallel, has a
temperate climate even if mountain ranges are present. The
value is 150 g/L (134–167 g/L) for men and 134 (117–150) for French population living at an altitude higher than 2500 m is
women ( p<10−6). For women, haemoglobin concentration is limited and so variations due to environmental pressure are of
higher in the age group 45–69 years than in the age group 16– little significance. Although individual variations, in particular
44 years (135 vs 133 g/L, p<10−6). A slight variation in haemo- ethnic characteristics, cannot be ignored, we can consider that
globin concentration, namely, a significant increase ( p<10−6), is in mainland France, individuals do not exhibit variation inher-
seen in women in the age groups (45–49 vs 50–54, p=10−3; ent to where they live or where the blood sample was col-
50–54 vs 55–59, p=0.399 (NS); 55–59 vs 60–69, p=8×10−4) lected. For this reason, the values that we report in this study
in comparison with lower age groups in which the level is can be used by all laboratories in mainland France, regardless
stable. For the MCV, the mean value is 87.3 fL (80.2–95.0) in of the technical analysis platform in use, and their adoption by
men and 87.5 (78.4–95.3) in women ( p=0.014). Regular all laboratories would eliminate the risk of interpretation errors
increases in the values with increasing age are seen in both sexes by physicians or patients.
(significant increase at each age group and in both sexes, Defining reference values is a delicate undertaking. The
p<10−6). The variation is approximately 3 fL for the age limits studies in the literature that include a sufficient number of
at the extremities. For the mean cell haemoglobin concentration, patients investigated with current methods for performing an
the mean value is 343 g/L (324–363) for men and 338 (319– FBC3 4 are limited. The FBC normal values given in French
358) for women ( p<10−6). For the mean corpuscular haemo- and foreign textbooks are also arbitrary, lacking references
globin, the mean value is 30.0 pg/cell (27.2–32.8) in men and and usually old.5 In September 1997, the National Health
29.7 (26.1–32.5) in women ( p<10−6). Accreditation and Evaluation Agency (Agence Nationale

Troussard X, et al. J Clin Pathol 2013;0:1–4. doi:10.1136/jclinpath-2013-201687 3

 Original article
d’Accréditation et d’Evaluation en Santé) published a docu-
ment giving FBC normal values based on a literature review
covering articles less than 10-years-old and involving more
than 200 patients.6 Laboratories are therefore faced with the
problem of providing normal values and not having national
recommendations. With accreditation programmes, this
problem is becoming a veritable cause for concern for direc-
tors of clinical pathology laboratories.
We have presented FBC normal data obtained between
2008 and 2010 in a population living in mainland France
with established preanalytical conditions and modern analyt-
ical methods based on recent technologies. The population
studied was large, consisting of 32 919 subjects selected after
analysis of advanced clinical and biological criteria combined
with a statistical/epidemiological approach to perform a final
smoothing for societal criteria liable to interfere with the
nutritional state (nutrient deficiencies, addiction, etc). The
population investigated in this study can be considered to be
representative of the current adult population of mainland
France. We have also presented normal reference values for
the population of healthy subjects aged 70–79 years, a popu-
lation that often receives little attention in the literature.7
For methodological reasons, this study did not include chil-
dren; it only included adult subjects. Paediatric normal values
have been presented in other works.8–10 Given the French ban
on entering the ethnic origin of an individual into an electronic
database, it is impossible to present the biological variation
related to ethnic origin, despite the multiethnic nature of the
French population. Modifications in white cells and neutrophils
count in subjects of African ancestry are known.11 12 The ques-
tionnaire used for the PHA does not take into consideration
exposure to environmental factors, pesticides, radiation, electro-
magnetic waves or genetic factors liable to modify certain haem-
atological factors. Another limitation of our study is the lack of
ability to eliminate in our population iron deficiency or any
haemoglobinopathies.
Our study did not envisage normal values for reticulocytes
as there is no reason to perform this investigation systematically
beyond cases of suspected anaemia or in a PHA. Parameters
provided by the auto-analysers and dependent on the analytical
techniques or the mode of result expression implemented by
the manufacturer, such as red cell distribution width or platelet
parameters other than mean platelet volume, were not
analysed.
The normal reference values presented here, very close to
other data,13 are proposed for use in everyday practice in order
to be able to affirm without ambiguity the abnormal nature of
any FBC parameter. Adoption of these normal values by all
laboratories in mainland France should make it possible to inter-
pret correctly an FBC from any adult subject, regardless of the
laboratory and its geographic location.
4 Troussard X, et al. J Clin Pathol 2013;0:1–4. doi:10.1136/jclinpath-2013-201687
View publication stats
Take home messages
▸ The full blood count is the most frequently requested
laboratory test: it guides later additional investigations
essential for diagnosing and monitoring the patient.
▸ Laboratories are faced with the problem of providing normal
values and not having national recommendations.
▸ We presented normal reference values in 32 919 subjects
considered to be representative of the French population.
▸ These normal values are proposed for use in everyday
practice. They make it possible to distinguish a normal
situation from a pathological situation.
Acknowledgements The authors thank all the collaborators, particularly Christine
Geslain, and the subjects participating in the study.
Contributors XT, EC and JC designed the study and wrote the manuscript. SV
performed the statistical analysis. VB, J-PC, CF, EM and VS discussed the results.
J-CL analysed the biological samples. JT and OL enrolled the patients and provided
the clinical data.
Competing interests None.
Ethics approval Institut inter Régional pour la Santé (IRSA).
Provenance and peer review Not commissioned; externally peer reviewed.
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