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Archives de pédiatrie
Volume 24, n° 5S
pages 56-513 (mai 2017)
Doi : 10.1016/S0929-693X(17)24003-2
Diagnostic biologique de la carence martiale chez l’enfant
Biological diagnosis of iron deficiency in children
 

I. Thuret
 Service d’onco-hématologie pédíatrique, CHU Timone Enfants, centre de référence des thalassémies, 264, rue Saint-Pierre, 13005 Marseille, France 

*Correspondance.
Résumé

Les recommandations nationales et internationales pour le diagnostic biologique de carence en fer préconisent le dosage de la ferritine sérique. Sa baisse est spécifique et, en l’absence d’inflammation, d’hémolyse ou d’atteinte hépatique associée, le signe le plus précoce de la carence martiale. L’Organisation mondiale de la santé propose des seuils définissant une carence à 12μg/L pour les enfants de moins de 5 ans (augmenté à 30μg/L en contexte inflammatoire) et 15μg/L au-delà. L’anémie ferriprive, microcytaire et hypochrome, ne survient qu’au stade le plus avancé de la carence martiale. Dans les études de populations pédiatriques, le diagnostic biologique de carence martiale est en règle établi sur la présence de plusieurs indices du métabolisme du fer ou érythrocytaires modifiés : baisse du coefficient de saturation de la transferrine (Tf), de la ferritine et du volume globulaire moyen, élévation du taux des protoporphyrines érythrocytaires liées au zinc et des récepteurs solubles de la transferrine (RsTf), et plus récemment baisse de l’hepcidine. Ces deux derniers marqueurs détectent mieux une carence martiale que la seule ferritinémie en contexte inflammatoire mais ne sont pas du domaine de la pratique courante. De même le contenu en hémoglobine (Hb) du réticulocyte (CHr), calculé par certains automates d’hémogramme et s’abaissant avant l’apparition de l’hypochromie et de l’anémie, est peu influencé par l’inflammation. En pratique clinique pédiatrique, le dosage de la ferritine reste préconisé pour le diagnostic biologique de carence en fer et peut être associé à celui de la protéine C réactive (CRP) pour une meilleure interprétation.

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Abstract

Measurement of serum ferritin (SF) is currently the laboratory test recommended for diagnosing iron deficiency. In the absence of an associated disease, a low SF value is an early and highly specific indicator of iron deficiency. The WHO criteria proposed to define depleted storage iron are 12μg/L for children under 5 years and 15μg/L for those over 5 years. A higher threshold of 30μg/L is used in the presence of infection or inflammation. Iron deficiency anemia, with typical low mean corpuscular volume and mean corpuscular hemoglobin, is only present at the end stage of iron deficiency. Other diagnostic tests for iron deficiency including iron parameters (low serum iron, increased total iron-binding capacity, low transferrin saturation) and erythrocyte traits (low mean corpuscular volume, increased zinc protoporphyrin) provide little additional diagnostic value over SF. In children, serum soluble transferrin receptor (sTfR) has been reported to be a sensitive indicator of iron deficiency and is relatively unaffected by inflammation. On the other hand, sTfR is directly related to extent of erythroid activity and not commonly used in clinical practice. In population surveys, approaches based on combinations of markers have been explored to improve the specificity and sensitivity of diagnostic. In addition to Hb value determination, a combination of parameters (among transferrin saturation, zinc protoporphyrin, mean corpuscular volume or serum ferritin) was generally used to assess iron deficiency. More recently sTfR/ ferritin index were evaluated, sTfR in conjunction with SF allowing to better distinguishing iron deficiency from inflammatory anemia. Also, hepcidin measurements appeared an interesting marker for diagnosing iron deficiency and identifying individuals in need of iron supplementation in populations where inflammatory or infectious diseases are frequently encountered. Reticulocyte Hb content (CHr) determination is an early parameter of iron deficiency erythropoiesis. CHr can be measured with several automated hematology analyzers and so, used for individual’s iron status assessment.

In addition to Hb concentration determination, individual’s iron status is commonly assessed in the pediatric clinical practice by the SF measurement accompanied by the determination of C-reactive protein for detection of a simultaneous acute infection and/or inflammation.

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