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Licensed Unlicensed Requires Authentication Published by De Gruyter January 27, 2023

Reference intervals for thyroid biomarkers to enhance the assessment of thyroid status in childhood and adolescence

  • Simona Ferraro EMAIL logo , Ester Luconi , Valeria Calcaterra ORCID logo , Erika Cordaro , Alice Bianchi , Cristina Cereda , Gianvincenzo Zuccotti , Peter Kavsak , Mario Plebani ORCID logo , Elia Mario Biganzoli EMAIL logo , Giuseppe Marano and Patrizia Boracchi



The determination of assay-dependent upper and lower reference limits (URL, LRL) of free triiodothyronine (FT3), free thyroxine (FT4), and thyroid stimulating hormone (TSH) during childhood and adolescence, is challenging.


Thyroid hormones were measured via the Abbott Alinity system in 502 euthyroid children partitioned in the following age groups: ≤2, 2.1–10, and 10.1–18 years. The 97.5th and 2.5th percentiles (URL and LRL) were derived according to CLSI EP28- A3c guidelines. Quantile regression models were used to assess: (a) 90% confidence intervals of the URL and LRL, (b) the effect of age on URL and LRL within each age class and on overall age range, (c) the difference between the URLs and LRLs estimated for each age partition with an estimate of the confidence interval divided by the reference interval being derived (CI/RI).


The CI/RI for the LRLs are smaller as compared to the URLs, except for FT4 for the 2.1–10 years age group. Considering the CI/RI and the overlap between CIs across the three age groups, one single LRL might be considered for TSH, FT3 and FT4 between 0 and 18 years. However, for the URL, there was a noticeable decrease in the URL over the 3 age groups for all three biomarkers, with there being no overlap in CIs for the URL between the ≤2 vs. the 10.1–19 years age groups.


A common LRL for TSH, FT4 and FT3 for patients aged ≤18 years may be utilized when these biomarkers are measured with the Alinity system. For the URLs the use of age-specific URLs for these biomarkers is recommended.

Corresponding authors: Simona Ferraro, Center of Functional Genomics and Rare Diseases, Department of Pediatrics, Buzzi Children’s Hospital, Milan, Italy, E-mail: ; and Elia Mario Biganzoli, Medical Statistics Unit, Department of Biomedical and Clinical Sciences L. Sacco, “Luigi Sacco” University Hospital, University of Milan, Milan, Italy; and Data Science Research Center, University of Milan, Milan, Italy, E-mail:
Simona Ferraro and Ester Luconi contributed equally to this work. Elia Mario Biganzoli, Giuseppe Marano and Patrizia Boracchi share senior authorship.
  1. Research funding: None declared.

  2. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  3. Competing interests: Authors state no conflict of interest.

  4. Informed consent: Informed consent was obtained from all individuals included in this study.

  5. Ethical approval: The institutional ethics committee approved the study (2022/EM/175) and the study was conducted in accordance with the Helsinki Declaration of 1975, as revised in 2008.


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Supplementary Material

This article contains supplementary material (

Received: 2022-10-18
Accepted: 2023-01-17
Published Online: 2023-01-27
Published in Print: 2023-06-27

© 2023 Walter de Gruyter GmbH, Berlin/Boston

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