Расстройства, связанные с глютеном: аллергия на пшеницу и нецелиакийная чувствительность к глютену. Часть 2

Камилова А.Т., Азимова Н.Д., Захарова И.Н. Расстройства, связанные с глютеном: аллергия на пшеницу и нецелиакийная чувствительность к глютену. Часть 2. Педиатрия. Consilium Medicum. 2023;4:246-251.
DOI: 10.26442/26586630.2023.4.202410

© ООО «КОНСИЛИУМ МЕДИКУМ», 2023 г.

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Kamilova AN, Azimova ND, Zakharova IN. Gluten-related disorders: wheat allergy and non-celiac gluten sensitivity. A review. Pediatrics. Consilium Medicum. 2023;4:246-251. DOI: 10.26442/26586630.2023.4.202410

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Аннотация

Расстройства, связанные с глютеном, постепенно превратились в эпидемиологически значимый феномен, привлекая внимание научного сообщества. Хотя они характеризуются особыми патогенетическими путями, участвующими в их развитии, расстройства имеют схожие клинические проявления, что затрудняет дифференциальную диагностику. В обзоре представлены современные данные об аллергии на пшеницу и нецелиакийной чувствительности к глютену. Хотя аллергия на пшеницу четко определяется клиническими формами и диагноз основан на определенных диагностических критериях, диагноз «нецелиакийная чувствительность к глютену», напротив, может рассматриваться только после исключения целиакии и аллергии на пшеницу. Данная статья предлагает практический методологический подход к изучению отличий в клинике, диагностике глютензависимых заболеваний.

Ключевые слова: глютен, пшеница, целиакия, аллергия на пшеницу, нецелиакийная чувствительность к глютену, диагностика

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Gluten-related disorders have gradually turned into an epidemiologically significant phenomenon, attracting the attention of the scientific community. Although they have specific pathogenetic pathways, they present with similar clinical manifestations, which makes their differential diagnosis challenging. The review presents current data on wheat allergy and non-celiac gluten sensitivity. Although wheat allergy is clearly defined by clinical forms and the diagnosis is based on specific diagnostic criteria, the diagnosis of non-celiac gluten sensitivity, on the contrary, can be considered only after excluding celiac disease and wheat allergy. This article describes a practical methodological approach to studying differences in the clinical presentation and diagnosis of gluten-dependent diseases.

Keywords: gluten, wheat, celiac disease, wheat allergy, non-celiac gluten sensitivity, diagnosis

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Список литературы

1. Catassi C, Bai JC, Bonaz B, et al. Non-Celiac Gluten sensitivity: the new frontier of gluten related disorders. Nutrients. 2013;5:3839-53.
2. Inomata N. Wheat allergy. Curr Opin Allergy Clin Immunol. 2009;9:238-43.
3. Volta U, Bardella MT, Calabrò A, et al. An Italian prospective multicenter survey on patients suspected of having non-celiac gluten sensitivity. BMC Med. 2014;12:85.
4. Buscarini E, Conte D, Cannizzaro R, et al. White paper of Italian Gastroenterology: delivery of services for digestive diseases in Italy: weaknesses and strengths. Dig Liver Dis. 2014;46:579-89.
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7. Ramesh S. Food allergy overview in children. Clin Rev Allergy Immunol. 2008;34:217-30.
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9. Cianferoni A. Wheat allergy: diagnosis and management. J Asthma Allergy. 2016;9:13.
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11. Ortiz C, Valenzuela R, Lucero AY. Celiac disease, non celiac gluten sensitivity and wheat allergy: comparison of 3 different diseases triggered by the same food. Rev Chil Pediatr. 2017;88(3):417-23.
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14. Wang J. Management of the patient with multiple food allergies. Curr Allergy Asthma Rep. 2010;10(4):271-7.
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2020;75(1):14-32.
16. Cooper B, Holmes G, Ferguson R, et al. Gluten-Sensitive Diarrhea without Evidence of Celiac Disease. Gastroenterology. 1980;79:801-6.
17. Skodje GI, Sarna VK, Minelle IH, et al. Fructan, Rather Than Gluten, Induces Symptoms in Patients with Self-Reported Non-Celiac Gluten Sensitivity. Gastroenterology.
2018, 154, 529-539.e2
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19. Ierardi E, Losurdo G, Piscitelli D, et al. Biological Markers for Non-Celiac Gluten Sensitivity: A Question Awaiting for a Convincing Answer. Gastroenterol Hepatol Bed Bench. 2018;11:203-8.
20. Reese I, Schäfer C, Kleine-Tebbe J, et al. Non-Celiac Gluten/Wheat Sensitivity (NCGS)-a Currently Undefined Disorder without Validated Diagnostic Criteria and of Unknown Prevalence: Position Statement of the Task Force on Food Allergy of the German Society of Allergology and Clinical Immunology (DGAKI). Allergo J Int. 2018;27:147-51.
21. Aziz I. The Global Phenomenon of Self-Reported Wheat Sensitivity. Am J Gastroenterol. 2018;113:945-8.
22. Francavilla R. Cristofori F. Verzillo L. Gentile and et al. MDRandomized Double-Blind Placebo-Controlled Crossover Trial for the Diagnosis of Non-Celiac Gluten Sensitivity in Children. Am J Gastroenterol. 2018;113:421-30. DOI:10.1038/ajg.2017.483
23. Carroccio A, Giambalvo O, La Blasca F, et al. Self-Reported Non-Celiac Wheat Sensitivity in High School Students: Demographic and Clinical Characteristics.Nutrients. 2017;9(7):771.
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25. Mansueto P, Soresi M, La Blasca F, et al. Body Mass Index and Associated Clinical Variables in Patients with Non-Celiac Wheat Sensitivity. Nutrients. 2019;11:1220.
26. Van Gils T, Nijeboer P, IJssennagger C, et al. Prevalence and Characterization of Self-Reported Gluten Sensitivity in The Netherlands. Nutrients. 2016;8:714.
27. The Study Group for Non-Celiac Gluten Sensitivity; Volta U, Bardella MT, et al. An Italian Prospective Multicenter Survey on Patients Suspected of Having Non-Celiac Gluten Sensitivity. BMC Med. 2014;12:85.
28. Cabrera-Chávez F, Figueroa-Salcido OG, Ontiveros N. Non-Celiac Gluten Sensitivity: An Update. Medicina (Kaunas, Lithuania). 2021;57:526. DOI:10.3390/medicina57060526
29. Mansueto P, Soresi M, Candore G, et al. Autoimmunity Features in Patients With Non-Celiac Wheat Sensitivity. Am J Gastroenterol. 2021;116:1015-23.
30. Camhi SS, Sangal K, Kenyon V, et al. Pediatric Nonceliac Gluten Sensitivity: A Gluten-related Disorder Treatment Center Experience. J Pediatr Gastroenterol Nutr. 2019;69(2):200-5. DOI:10.1097/MPG.0000000000002335
31. Potter MDE, Walker MM, Jones MP, et al. Wheat Intolerance and Chronic Gastrointestinal Symptoms in an Australian Population-Based Study: Association Between Wheat Sensitivity, Celiac Disease and Functional Gastrointestinal Disorders. Am J Gastroenterol. 2018;113:1036-44.
32. Ontiveros N, Rodríguez-Bellegarrigue C, Galicia-Rodríguez G, et al. Prevalence of Self-Reported Gluten-Related Disorders and Adherence to a Gluten-Free Diet in Salvadoran Adult Population. Int J Environ Res Public Health. 2018;15:786.
33. Vazquez-Roque MI, Camilleri M, Smyrk T, et al. A Controlled Trial of Gluten-Free Diet in Patients with Irritable Bowel Syndrome-Diarrhea: Effects on Bowel Frequency and Intestinal Function. Gastroenterology. 2013;144:903-11.e3.
34. Carroccio A, Giannone G, Mansueto P, et al. Duodenal and Rectal Mucosa Inflammation in Patients with Non-Celiac Wheat Sensitivity. Clin Gastroenterol Hepatol. 2019;17:682-90.e3
35. Zanini B, Villanacci V, Marullo M, et al. Duodenal Histological Features in Suspected Non-Celiac Gluten Sensitivity: New Insights into a Still Undefined Condition. Virchows Arch. 2018;473:229-34.
36. Mansueto P, Di Liberto D, Fayer F, et al. TNF-α, IL‑17, and IL‑22 Production in the Rectal Mucosa of Nonceliac Wheat Sensitivity Patients: Role of Adaptive Immunity. Am J Physiol Gastrointest Liver Physiol. 2020;319:G281-8.
37. Uhde M, Ajamian M, Caio G, et al. Intestinal Cell Damage and Systemic Immune Activation in Individuals Reporting Sensitivity to Wheat in the Absence of Coeliac Disease. Gut. 2016;65:1930-7.
38. Herrera MG, Pizzuto M, Lonez C, et al. Large Supramolecular Structures of 33-Mer Gliadin Peptide Activate Toll-like Receptors in Macrophages. Nanomed Nanotechnol Biol Med. 2018;14:1417-27.
39. Catassi C, Elli L, Bonaz B, et al. Diagnosis of Non-Celiac Gluten Sensitivity (NCGS): The Salerno Experts’ Criteria. Nutrients. 2015;7:4966-77. DOI:10.3390/nu7064966
40. Khan A, Suarez MG, Murray JA. Nonceliac Gluten and Wheat Sensitivity. Clin Gastroenterol Hepatol. 2020;18:1913-22.e1.
41. Lionetti E, Pulvirenti A, Vallorani M, et al. Re-Challenge Studies in Non-Celiac Gluten Sensitivity: A Systematic Review and Meta-Analysis. Front Physiol. 2017;8:621.
42. Liu L, Ikeda TM, Branlard G, et al. Comparison of low molecular weight glutenin subunits identified by SDS-PAGE, 2-DE, MALDI-TOF-MS and PCR in common wheat. BMC Plant Biol. 2010;10:124. DOI:10.1186/1471-2229-10-124
43. Dale HF, Hatlebakk JG, Hovdenak N, et al. The Effect of a Controlled Gluten Challenge in a Group of Patients with Suspected Non-Coeliac Gluten Sensitivity: A Randomized, Double-Blind Placebo-Controlled Challenge. Neurogastroenterol Motil. 2018:30: e13332.
44. Uhde M, Caio G, De Giorgio R, et al. Subclass Profile of IgG Antibody Response to Gluten Differentiates Nonceliac Gluten Sensitivity from Celiac Disease. Gastroenterology. 2020;159:1965-1967.e2
45. Losurdo G, Piscitelli D, Pezzuto F, et al. T Helper Lymphocyte and Mast Cell Immunohistochemical Pattern in Nonceliac Gluten Sensitivity. Gastroenterol Res Pract. 2017;2017:1-9.
46. Hallert C, Svensson M, Tholstrup J, et al. Clinical trial: B vitamins improve health in patients with coeliac disease living on a gluten-free diet. Aliment Pharmacol Ther.
2009;29(8):811-6.
47. Arias-Gastelum M, Cabrera-Chávez F, de Jesus Vergara-Jiménez M, Ontiveros N. The Gluten-Free Diet: Access and Economic Aspects and Impact on Lifestyle. Nutr Diet Suppl. 2018;10:27-34.
48. Khan, A, Suarez MG, Murray JA. Nonceliac Gluten and Wheat Sensitivity. Clin Gastroenterol Hepatol. 2020;18:1913-22.e1.
49. Zingone F, Bartalini C, Siniscalchi M, R et al. Alterations in Diets of Patients with Nonceliac Gluten Sensitivity Compared with Healthy Individuals. Clin Gastroenterol Hepatol. 2017;15:63-8.e2
50. Dieterich W, Schuppan D, Schink M, et al. Influence of Low FODMAP and Gluten-Free Diets on Disease Activity and Intestinal Microbiota in Patients with Non-Celiac Gluten Sensitivity. Clin Nutr. 2019;38:697-707.
51. Roszkowska A, Pawlicka M, Mroczek A, et al. Non-Celiac Gluten Sensitivity: A Review. Medicina. 2019;55(6):222. DOI:10.3390/medicina55060222
52. Mankowska-Wierzbicka D, Stelmach-Mardas M. Noncoeliac Wheat Sensitivity and Diet. Curr Opin Clin Nutr Metab Care. 2020;23:322-7.
53. Азизова Г.К., Камилова А.Т., Умарназарова З.Е., и др. Нецелиакийная чувствительность к глютену – диагностическая проблема в педиатрии. Вопросы детской диетологии. 2023;21(2):70-6 [Azizova GK, Kamilova AT, Umarnazarova ZE, et al. Non-celiac gluten sensitivity: a diagnostic challenge in pediatrics. Vopr. det. dietol. (Pediatric nutrition). 2023;21(2):70-6 (in Russian)]. DOI:10.20953/1727-5784-2023-2-70-76

________________________________________________

1. Catassi C, Bai JC, Bonaz B, et al. Non-Celiac Gluten sensitivity: the new frontier of gluten related disorders. Nutrients. 2013;5:3839-53.
2. Inomata N. Wheat allergy. Curr Opin Allergy Clin Immunol. 2009;9:238-43.
3. Volta U, Bardella MT, Calabrò A, et al. An Italian prospective multicenter survey on patients suspected of having non-celiac gluten sensitivity. BMC Med. 2014;12:85.
4. Buscarini E, Conte D, Cannizzaro R, et al. White paper of Italian Gastroenterology: delivery of services for digestive diseases in Italy: weaknesses and strengths. Dig Liver Dis. 2014;46:579-89.
5. Tovoli F, Masi C, Guidetti E, et al. Clinical and diagnostic aspects of gluten related disorders. World journal of clinical cases. 2015;3:275-84.
6. Taraghikhah N, Ashtari S, Asri N, et al. An updated overview of spectrum of gluten-related disorders: clinical and diagnostic aspects. BMC Gastroenterol. 2020;20(1):258. DOI:10.1186/s12876-020-01390-0
7. Ramesh S. Food allergy overview in children. Clin Rev Allergy Immunol. 2008;34:217-30.
8. Elli L, Branchi F, Tomba C, et al. Diagnosis of gluten related disorders: Celiac disease, wheat allergy and non-celiac gluten sensitivity. World J Gastroenterol. 2015;21(23):7110-9. DOI:10.3748/wjg.v21.i23.7110
9. Cianferoni A. Wheat allergy: diagnosis and management. J Asthma Allergy. 2016;9:13.
10. Tanabe S. Analysis of food allergen structures and development of foods for allergic patients. Biosci Biotechnol Biochem. 2008:0802050767.
11. Ortiz C, Valenzuela R, Lucero AY. Celiac disease, non celiac gluten sensitivity and wheat allergy: comparison of 3 different diseases triggered by the same food. Rev Chil Pediatr. 2017;88(3):417-23.
12. Scherf KA, Brockow K, Biedermann T, et al. Wheatdependent exercise-induced anaphylaxis. Clin Exp Allergy. 2016;46(1):10-20.
13. Soares-Weiser K, Takwoingi Y, Panesar SS, et al. The diagnosis of food allergy: a systematic review and meta-analysis. Allergy. 2014;69(1):76-86.
14. Wang J. Management of the patient with multiple food allergies. Curr Allergy Asthma Rep. 2010;10(4):271-7.
15. Meyer R, Chebar Lozinsky A, Fleischer DM, et al. Diagnosis and management of non-IgE gastrointestinal allergies in breastfed infants-an EAACI position paper. Allergy.
2020;75(1):14-32.
16. Cooper B, Holmes G, Ferguson R, et al. Gluten-Sensitive Diarrhea without Evidence of Celiac Disease. Gastroenterology. 1980;79:801-6.
17. Skodje GI, Sarna VK, Minelle IH, et al. Fructan, Rather Than Gluten, Induces Symptoms in Patients with Self-Reported Non-Celiac Gluten Sensitivity. Gastroenterology.
2018, 154, 529-539.e2
18. Carroccio A, Rini G, Mansueto P. Non-Celiac Wheat Sensitivity Is a More Appropriate Label Than Non-Celiac Gluten Sensitivity. Gastroenterology. 2014:146;320-1.
19. Ierardi E, Losurdo G, Piscitelli D, et al. Biological Markers for Non-Celiac Gluten Sensitivity: A Question Awaiting for a Convincing Answer. Gastroenterol Hepatol Bed Bench. 2018;11:203-8.
20. Reese I, Schäfer C, Kleine-Tebbe J, et al. Non-Celiac Gluten/Wheat Sensitivity (NCGS)-a Currently Undefined Disorder without Validated Diagnostic Criteria and of Unknown Prevalence: Position Statement of the Task Force on Food Allergy of the German Society of Allergology and Clinical Immunology (DGAKI). Allergo J Int. 2018;27:147-51.
21. Aziz I. The Global Phenomenon of Self-Reported Wheat Sensitivity. Am J Gastroenterol. 2018;113:945-8.
22. Francavilla R. Cristofori F. Verzillo L. Gentile and et al. MDRandomized Double-Blind Placebo-Controlled Crossover Trial for the Diagnosis of Non-Celiac Gluten Sensitivity in Children. Am J Gastroenterol. 2018;113:421-30. DOI:10.1038/ajg.2017.483
23. Carroccio A, Giambalvo O, La Blasca F, et al. Self-Reported Non-Celiac Wheat Sensitivity in High School Students: Demographic and Clinical Characteristics.Nutrients. 2017;9(7):771.
24. Roszkowska A, Pawlicka M, Mroczek A, et al. Non-Celiac Gluten Sensitivity: A Review. Medicina. 2019;55(6):222. DOI:10.3390/medicina55060222
25. Mansueto P, Soresi M, La Blasca F, et al. Body Mass Index and Associated Clinical Variables in Patients with Non-Celiac Wheat Sensitivity. Nutrients. 2019;11:1220.
26. Van Gils T, Nijeboer P, IJssennagger C, et al. Prevalence and Characterization of Self-Reported Gluten Sensitivity in The Netherlands. Nutrients. 2016;8:714.
27. The Study Group for Non-Celiac Gluten Sensitivity; Volta U, Bardella MT, et al. An Italian Prospective Multicenter Survey on Patients Suspected of Having Non-Celiac Gluten Sensitivity. BMC Med. 2014;12:85.
28. Cabrera-Chávez F, Figueroa-Salcido OG, Ontiveros N. Non-Celiac Gluten Sensitivity: An Update. Medicina (Kaunas, Lithuania). 2021;57:526. DOI:10.3390/medicina57060526
29. Mansueto P, Soresi M, Candore G, et al. Autoimmunity Features in Patients With Non-Celiac Wheat Sensitivity. Am J Gastroenterol. 2021;116:1015-23.
30. Camhi SS, Sangal K, Kenyon V, et al. Pediatric Nonceliac Gluten Sensitivity: A Gluten-related Disorder Treatment Center Experience. J Pediatr Gastroenterol Nutr. 2019;69(2):200-5. DOI:10.1097/MPG.0000000000002335
31. Potter MDE, Walker MM, Jones MP, et al. Wheat Intolerance and Chronic Gastrointestinal Symptoms in an Australian Population-Based Study: Association Between Wheat Sensitivity, Celiac Disease and Functional Gastrointestinal Disorders. Am J Gastroenterol. 2018;113:1036-44.
32. Ontiveros N, Rodríguez-Bellegarrigue C, Galicia-Rodríguez G, et al. Prevalence of Self-Reported Gluten-Related Disorders and Adherence to a Gluten-Free Diet in Salvadoran Adult Population. Int J Environ Res Public Health. 2018;15:786.
33. Vazquez-Roque MI, Camilleri M, Smyrk T, et al. A Controlled Trial of Gluten-Free Diet in Patients with Irritable Bowel Syndrome-Diarrhea: Effects on Bowel Frequency and Intestinal Function. Gastroenterology. 2013;144:903-11.e3.
34. Carroccio A, Giannone G, Mansueto P, et al. Duodenal and Rectal Mucosa Inflammation in Patients with Non-Celiac Wheat Sensitivity. Clin Gastroenterol Hepatol. 2019;17:682-90.e3
35. Zanini B, Villanacci V, Marullo M, et al. Duodenal Histological Features in Suspected Non-Celiac Gluten Sensitivity: New Insights into a Still Undefined Condition. Virchows Arch. 2018;473:229-34.
36. Mansueto P, Di Liberto D, Fayer F, et al. TNF-α, IL‑17, and IL‑22 Production in the Rectal Mucosa of Nonceliac Wheat Sensitivity Patients: Role of Adaptive Immunity. Am J Physiol Gastrointest Liver Physiol. 2020;319:G281-8.
37. Uhde M, Ajamian M, Caio G, et al. Intestinal Cell Damage and Systemic Immune Activation in Individuals Reporting Sensitivity to Wheat in the Absence of Coeliac Disease. Gut. 2016;65:1930-7.
38. Herrera MG, Pizzuto M, Lonez C, et al. Large Supramolecular Structures of 33-Mer Gliadin Peptide Activate Toll-like Receptors in Macrophages. Nanomed Nanotechnol Biol Med. 2018;14:1417-27.
39. Catassi C, Elli L, Bonaz B, et al. Diagnosis of Non-Celiac Gluten Sensitivity (NCGS): The Salerno Experts’ Criteria. Nutrients. 2015;7:4966-77. DOI:10.3390/nu7064966
40. Khan A, Suarez MG, Murray JA. Nonceliac Gluten and Wheat Sensitivity. Clin Gastroenterol Hepatol. 2020;18:1913-22.e1.
41. Lionetti E, Pulvirenti A, Vallorani M, et al. Re-Challenge Studies in Non-Celiac Gluten Sensitivity: A Systematic Review and Meta-Analysis. Front Physiol. 2017;8:621.
42. Liu L, Ikeda TM, Branlard G, et al. Comparison of low molecular weight glutenin subunits identified by SDS-PAGE, 2-DE, MALDI-TOF-MS and PCR in common wheat. BMC Plant Biol. 2010;10:124. DOI:10.1186/1471-2229-10-124
43. Dale HF, Hatlebakk JG, Hovdenak N, et al. The Effect of a Controlled Gluten Challenge in a Group of Patients with Suspected Non-Coeliac Gluten Sensitivity: A Randomized, Double-Blind Placebo-Controlled Challenge. Neurogastroenterol Motil. 2018:30: e13332.
44. Uhde M, Caio G, De Giorgio R, et al. Subclass Profile of IgG Antibody Response to Gluten Differentiates Nonceliac Gluten Sensitivity from Celiac Disease. Gastroenterology. 2020;159:1965-1967.e2
45. Losurdo G, Piscitelli D, Pezzuto F, et al. T Helper Lymphocyte and Mast Cell Immunohistochemical Pattern in Nonceliac Gluten Sensitivity. Gastroenterol Res Pract. 2017;2017:1-9.
46. Hallert C, Svensson M, Tholstrup J, et al. Clinical trial: B vitamins improve health in patients with coeliac disease living on a gluten-free diet. Aliment Pharmacol Ther.
2009;29(8):811-6.
47. Arias-Gastelum M, Cabrera-Chávez F, de Jesus Vergara-Jiménez M, Ontiveros N. The Gluten-Free Diet: Access and Economic Aspects and Impact on Lifestyle. Nutr Diet Suppl. 2018;10:27-34.
48. Khan, A, Suarez MG, Murray JA. Nonceliac Gluten and Wheat Sensitivity. Clin Gastroenterol Hepatol. 2020;18:1913-22.e1.
49. Zingone F, Bartalini C, Siniscalchi M, R et al. Alterations in Diets of Patients with Nonceliac Gluten Sensitivity Compared with Healthy Individuals. Clin Gastroenterol Hepatol. 2017;15:63-8.e2
50. Dieterich W, Schuppan D, Schink M, et al. Influence of Low FODMAP and Gluten-Free Diets on Disease Activity and Intestinal Microbiota in Patients with Non-Celiac Gluten Sensitivity. Clin Nutr. 2019;38:697-707.
51. Roszkowska A, Pawlicka M, Mroczek A, et al. Non-Celiac Gluten Sensitivity: A Review. Medicina. 2019;55(6):222. DOI:10.3390/medicina55060222
52. Mankowska-Wierzbicka D, Stelmach-Mardas M. Noncoeliac Wheat Sensitivity and Diet. Curr Opin Clin Nutr Metab Care. 2020;23:322-7.
53. Azizova GK, Kamilova AT, Umarnazarova ZE, et al. Non-celiac gluten sensitivity: a diagnostic challenge in pediatrics. Vopr. det. dietol. (Pediatric nutrition). 2023;21(2):70-6 (in Russian). DOI:10.20953/1727-5784-2023-2-70-76

Авторы

А.Т. Камилова*¹, Н.Д. Азимова¹, И.Н. Захарова²

¹Республиканский специализированный научно-практический медицинский центр педиатрии Минздрава Республики Узбекистан, Ташкент, Узбекистан;
²ФГБОУ ДПО «Российская медицинская академия непрерывного профессионального образования» Минздрава России, Москва, Россия
*okamilova@mail.ru

________________________________________________

Altinoy Т. Kamilova*¹, Noiba D. Azimova¹, Irina N. Zakharova²

¹Republican Specialized Scientific Practice Medical Center of Pediatrics, Tashkent, Uzbekistan;
²Russian Medical Academy of Continuous Professional Education, Moscow, Russia
*okamilova@mail.ru

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