Children's gluten allergy: symptoms, dangerous foods, diet

Detailed description of the study

Gluten is one of the main proteins found in wheat. It is found in slightly smaller quantities in other cereal crops. Like any other protein, gluten can be an allergen and trigger the activation of immune cells. Most often, allergies are detected to products that contain wheat. Sometimes even inhaling wheat flour provokes a reaction. Wheat allergy involves an immune response not only to gluten, but also potentially to other classes of proteins - albumin, globulin. Gluten allergy is sometimes confused with celiac disease, or celiac disease. In both cases, there is an excessive immune response to the protein, but the mechanisms of development of these conditions are different. The disease most often occurs among preschool children, whose bodies are predisposed to such reactions (due to the fact that the immune system is at the stage of formation). Many of them outgrow the allergy by age 16, but in adults it can occur due to cross-sensitivity to grass pollen. The presence of allergies in parents and close relatives increases the risk of its development in children. In people of all ages who suffer from allergies, manifestations of the disease can occur within a period of time from several minutes to hours after ingesting foods containing gluten. Signs of an allergy include: - Swelling, itching or irritation in the mouth and throat - Hives, itchy skin - Swelling of the skin - Headache - Difficulty breathing - Nausea - Abdominal cramps - Loose bowel movements Some people are susceptible to a sudden and life-threatening reaction called anaphylaxis, which manifests itself: Swelling of the upper respiratory tract, accompanied by shortness of breath, cough Serious difficulty breathing Pallor of the skin Dizziness As well as anaphylactic shock (a severe condition that can develop following anaphylaxis), which is characterized by pale skin, decreased blood pressure, rapid heartbeat , fainting and even coma. This condition is life-threatening and requires immediate medical attention. Foods that may contain wheat proteins include: baked goods, soy sauce, organ meats, ice cream, food starch. However, gluten is not only found in the obvious grain sources. It is often included in chewing gum, cosmetic products and plasticine.

Modern view on the diagnosis and treatment of celiac enteropathy in young children

The problem of celiac enteropathy (GE) is currently becoming particularly relevant, given modern data on its prevalence. Many pediatricians are convinced that GE is a rare disease of children in the first years of life, which has typical clinical manifestations of malabsorption syndrome [1, 5].

Modern epidemiological data indicate that the incidence of GE in the population reaches 1%. This makes GE one of the most common genetically determined diseases of the gastrointestinal tract. The clinical signs of HE are highly variable, which makes its timely diagnosis difficult [1]. Insufficient attention is paid to extraintestinal symptoms of GE. These include various deficiency conditions (iron deficiency anemia, refractory to therapy, osteoporosis), skin manifestations (cheilitis, dermatitis), and impaired physical and sexual development. Children with this pathology are observed for a long time by many specialists, undergo repeated examinations and receive drug therapy without significant effect, which negatively affects their quality of life and aggravates the prognosis of the disease [2–4].

GE (celiac disease) is a chronic genetically determined autoimmune T-cell-mediated enteropathy, characterized by persistent intolerance to specific endosperm proteins of the grain of some cereal crops with the development of hyperregenerative atrophy of the mucous membrane of the small intestine and associated malabsorption syndrome.

“Toxic” for patients with HE are prolamins (alcohol-soluble proteins rich in glutamine and proline), namely: wheat gliadin, rye secalin and barley hordenin. The membership of oat avenin proteins in this group has recently been discussed, but in practice it should still be classified as “toxic” [4]. In the medical literature, for the sake of brevity, all cereal proteins that are dangerous for patients with GE are referred to as “gluten.” The triggering factor for the development of GE is the consumption of gluten and the presence of a genetic predisposition (HLA-DQ2 or DQ8 haplotypes diagnosed in patients) [2].

Clinical picture of celiac enteropathy

Typical symptoms of GE - abdominal pain, vomiting, loss of appetite, copious foul stools, diarrhea, flatulence, delayed physical development - are more common at an early age, developing 1.5-2 months after the introduction of cereal products into the diet, possibly after an infectious diseases. Also characteristic are increased bowel movements, polyfecality, steatorrhea, increased abdominal circumference against the background of weight loss, signs of malnutrition (loss of body weight, thinning of the subcutaneous fat layer), decreased muscle tone, loss of previously acquired skills and abilities, and hypoproteinemic edema [4].

In accordance with the latest ESPGHAN (European Society of Pediatric Gastroenterology, Hepatology and Nutrition) recommendations, children and adolescents who have the following conditions or symptoms should be screened for the presence of GE: chronic or recurrent diarrhea, nausea or vomiting, chronic pain syndrome, feeling of distension, chronic constipation, developmental delay, weight loss, growth retardation, delayed sexual development, amenorrhea, iron deficiency anemia refractory to therapy, spontaneous fractures (osteopenia/osteoporosis), recurrent aphthous stomatitis, dermatitis herpetiformis, increased liver enzyme activity, chronic fatigue syndrome [4]. Diagnosis of GE in such cases is usually not difficult, and timely administration of a gluten-free diet quite quickly leads to relief of clinical symptoms and normalization of the rate of physical and neuropsychic development of the child.

The detection of one or more of these symptoms in a child requires a mandatory serological examination (determining the concentration of IgA antibodies to tissue transglutaminase) on an outpatient basis. Currently, this test is not available in all medical institutions. If an increased level of antibodies to tissue transglutaminase is detected, the child is sent for hospitalization to a hospital that has tools for targeted diagnosis of celiac disease for a more detailed examination and endoscopic examination of the duodenum and jejunum with a biopsy taken for histological analysis (required!). It must be remembered that examination of a child with suspected GE, both serological and morphological, must be carried out strictly against the background of a normal diet!

Diagnostics

The diagnosis of GE is made on the basis of:

• characteristic clinical manifestations and anamnesis data;
• positive results of serological examination;
• histological diagnosis based on the assessment of elementary damage (increased number of interepithelial T-lymphocytes (IEL)), structural changes (shortening of villi and crypt hyperplasia).

Instrumental research methods

Patients undergo esophagogastroduodenointestinoscopy with a biopsy of the distal portions of the duodenum and the initial parts of the jejunum. Endoscopic signs of GE: there are no pathognomonic endoscopic signs of celiac disease. The following general signs are described: absence of folds in the small intestine (intestine in the form of a “pipe”) and transverse striations of the folds [5, 8, 9].

Laboratory research methods

Histological features of celiac enteropathy

In the active period of GE, diffuse changes in the mucous membrane of the small intestine are observed, which are referred to as “atrophic enteropathy,” with shortening of the villi up to complete disappearance, as well as an increase in the depth of the crypts and a decrease in the number of goblet cells. The presence of deep crypts and increased mitotic activity, indicating hyperplasia of the generative region, serve as the basis for establishing the diagnosis of “Hyperregenerative atrophy” [3–5]. Interepithelial lymphocytic infiltration and lymphoplasmacytic infiltration of the lamina propria of the small intestinal mucosa are characteristic, indicating the presence of an ongoing immunological process causing damage to villous enterocytes.

Serological tests for the diagnosis of celiac enteropathy

Children with suspected GE should undergo a serological test to confirm the diagnosis. It is possible to detect antigliadin (AGA), antiendomysial (AEMA) antibodies, as well as antibodies to tissue transglutaminase (anti-tTG) in the blood. The most informative is the determination of antibodies to the cells of the intestinal mucosa: IgA to tissue transglutaminase (anti-tTG) and IgA to endomysium (AEMA). Currently, these tests, as noted above, are not available in all clinics. The most common test is anti-agliadin antibodies (AGA), but its use is not recommended due to low specificity and sensitivity [3]. It must be taken into account that the assessment of AGA content will be unreliable in patients with an initially low IgA value [7], so serum IgA should be determined first.

Treatment of Celiac Enteropathy

Diet

The only method of treating GE and preventing its complications is a strict and lifelong gluten-free diet! Elimination diet therapy is based on the complete exclusion of gluten-containing foods from the diet. It is fundamentally important to avoid eating not only those products that contain “obvious” gluten (bread, bakery and pasta products, wheat, semolina, barley, pearl barley, semi-finished breaded meat, fish and vegetable dishes, dumplings, dumplings, etc. .), but also those that contain “hidden” gluten, used as food additives during the production process (sauces, confectionery, chips, kvass, etc.) [5, 6]. Parents need to explain the importance of clearly monitoring the composition of products indicated on the packaging.

Currently on the Russian market there are gluten-free products made from “safe” grains, which have good taste and allow diversification of children’s diets. A properly formulated gluten-free diet is absolutely complete, ensures normal rates of growth and development of the child, prevents relapses of the disease and prevents the risk of developing serious complications [1, 5]. A child following a gluten-free diet should and can lead a normal life and does not need constant hospitalization or registration due to disability.

Children with GE can eat meat, fish, vegetables, fruits, eggs, dairy products, rice, legumes, buckwheat, corn, millet, chocolate, marmalade, some candies, marshmallows, and some types of ice cream.

Specialized gluten-free products are recommended for feeding patients with celiac disease. Acceptable gluten levels are < 2 ppm (ppm - "pro pro mille" - one part per million; 1 ppm = 1/1000000 = 0.000001 = 1 × 10-6 = 0.001‰ = 0.0001%) (less than 0.2 mg/100 g dry product) for foods that are naturally gluten-free, and 20–200 ppm for foods from which gluten is removed during production [3, 4].

Almost all milk formulas for feeding children in the first year of life and all medicinal formulas do not contain gluten. In Russia, certified products for nutrition of patients with celiac enteropathy are presented (Germany) and “Doctor Cher” (Italy).

Recently, a new product has appeared on the baby food market - gluten-free Babyki cookies. According to expert opinions, cookies do not contain genetically modified microorganisms, nanomaterials, dyes, artificial stabilizers, preservatives and meet Russian and international requirements for complementary feeding products. Gluten-free “Babiki” cookies are a unique product: they are made from corn flour and do not contain gluten, the most suitable option for all babies who are starting to get acquainted with cereal dishes, recommended for GE. Cookies are an important cereal part of a baby’s diet, and cereal products provide easy-to-digest protein, vitamins and minerals, as well as high calorie content, which gives a long-lasting feeling of satiety, and dietary fiber for optimal intestinal function. Eating cookies independently by a child helps develop coordination of movements of the head, hands, eyes, and the consistency of the product contributes to the formation of chewing skills.

Drug therapy

Drug therapy for GE is auxiliary and may be vital. It is mainly aimed at correcting metabolic disorders that have developed against the background of malabsorption syndrome.

Correction of digestion processes is carried out by prescribing highly active pancreatic enzymes (Creon, Micrasim, Ermital). The dose of the drug is determined by the age of the child, the nature of the diet and the severity of steatorrhea. Against the background of severe diarrhea, mucocytoprotective adsorbents (Smecta) can be used. If necessary, correction of intestinal microflora disorders is indicated. With the development of hypoproteinemic edema, in order to restore the oncotic pressure of the blood, intravenous drip administration of a 10% albumin solution is used, however, when prescribing parenteral nutrition, preference should be given to sets of amino acids. Against the background of restoration of protein concentration in the blood, it is advisable to prescribe non-steroidal anabolic drugs, such as potassium orotate, glycine, etc., and in some cases, steroid drugs. Hypoglycemia with GE occurs in infants and young patients more often than in older children, and is directly related to impaired intestinal absorption. Hypoglycemia is corrected by intravenous administration of 5–10% glucose solution [5, 8].

Fluid and electrolyte disorders require fluid therapy based on the deficiency of water and electrolytes. The basic solutions for infusion therapy are isotonic sodium chloride solution and 5–10% glucose solution, the ratio of which is determined by the type of dehydration (isotonic or hypotonic). To correct the potassium level in the blood, use a 4–7.5% solution of potassium chloride. The dose is determined by potassium deficiency. The drug is administered only intravenously, drip-wise, slowly, pre-diluted with isotonic sodium chloride solution to a concentration not exceeding 70 mmol/l [4, 5].

Malabsorption of calcium and vitamin D is corrected by administering calcium and prescribing vitamin D3 supplements.

The use of glucocorticoid drugs for GE is indicated in cases of severe disease with significant impairment of physical development, for example, with grade III malnutrition, and as replacement therapy for the correction of adrenal insufficiency. Possible negative consequences of long-term therapy with glucocorticoid drugs, especially in high doses, may be an increase in osteoporosis up to episodes of spontaneous fractures. In order to correct secondary transient hypothyroidism, children with GE can be prescribed L-thyroxine 25 in small doses (5 mg/kg per day) for up to 1 month while monitoring the serum levels of thyroid-stimulating hormone, triiodothyronine and thyroxine [3, 5].

Observation

Dispensary observation of children with GE is lifelong. Frequency of observation: after diagnosis during the first 2 years - once every 6 months, from the 3rd year of observation, subject to stable remission and regular sufficient weight gain - once a year. Examination during clinical observation: interview, examination, measurement of height and weight, coprogram, clinical blood test, biochemical blood test; according to indications - endoscopic and serological examination.

Endoscopic and serological examinations are mandatory upon first admission and during the active period of the disease. A repeat endoscopic examination is prescribed 6–12 months after starting a gluten-free diet or exiting the active period of the disease, or if the patient’s condition worsens.

Serological testing should be repeated annually. The patient's relatives are also recommended to undergo a serological examination, and if elevated titers of the corresponding antibodies are detected, to conduct a full range of examinations, including endoscopic and histological examination.

Preventive vaccinations are carried out during the period of remission according to a gentle scheme.

Conclusion

1. Diagnosis of GE requires a comprehensive assessment of clinical, serological and histological data.
2. All specialists dealing with the problem of GE must take into account the variability of the clinical, endoscopic and histological picture of the disease when assessing the patient’s condition. This is the key to high-quality and timely diagnosis.
3. The only method for treating GE and preventing its complications is a strict and lifelong gluten-free diet!

Literature

1. Zakharova I.B. Koning F. Such insidious celiac disease... // Med. newspaper. 2012; 46:2–3.
2. Memeo L. Report “Celiac disease: histological aspects and differential diagnosis.” Congress of Pediatric Gastroenterologists, Moscow. 2010.
3. Zaprudnov A. M. Intestinal diseases in children. M.: Anacharis. 2009. 119–129.
4. Belmer S.V., Mukhina Yu.G., Gasilina T.V. et al. Information letter “Draft standards for the diagnosis and treatment of celiac disease in children.” X Congress of Pediatric Gastroenterologists of Russia, Moscow. 2003.
5. Korovina N.A. Zakharova I.N., Berezhnaya I.V. Celiac disease: possibilities of diagnosis and treatment in children // Russian Medical Journal. 2004. No. 13. pp. 786–789.
6. Parfenov A.I. Mysteries of gluten enteropathy // Moscow Medical Journal. 1997; May, 24–26.
7. Revnova O. M., Lyle H. B. Clinical aspects of celiac disease in children // Pediatrics. 2000; 5: 107–109.
8. Cherkasova T. A., Snigireva D. G. et al. Celiac disease (textbook). 2000. 3–5, 10, 17–18.
9. Celiac disease. WGO-OMGE: Practice guidelines // World Gastroenterology News. 2005; 10(2), Suppl. 1–8: 1–8.

T. M. Osheva, Candidate of Medical Sciences N. S. Zhuravleva, Candidate of Medical Sciences, Associate Professor O. V. Osipenko, Candidate of Medical Sciences

State Budgetary Educational Institution of Higher Professional Education UGMA Ministry of Health of the Russian Federation, Ekaterinburg

Contact information for authors for correspondence

Harmful protein: how to recognize the threat

Allergic reactions occur immediately after eating foods containing gluten. The intestines suffer from this - the beneficial microflora dies, dysbiosis and digestive disorders occur, the patient is debilitated by the consequences of impaired motility - diarrhea or constipation.

There is another danger - celiac disease. In this case, gluten aversion or intolerance is inherited. The solution to the problem will be to follow a special diet that excludes irritating foods.

Celiac disease is a severe genetically determined autoimmune disease that requires a review of the diet and the exclusion of foods containing gluten. However, the body's sensitivity to elastic protein, resulting in gastrointestinal disorders, is not all the unpleasant consequences of overusing foods rich in gluten.

• Deterioration of brain function - this is exactly what happens if we often consume baked goods and other sources of harmful protein. The fruits of addiction to tasty and unhealthy food are Alzheimer's disease, disorders of the heart and blood vessels.
• Insufficient absorption of nutrients - blame the stickiness of gluten for this. The pasty substance that gets into our intestines not only irritates its walls, but also prevents vitamins, microelements and other useful substances that enter the body with food from being absorbed normally.

We found out what gluten is, why it is harmful and even dangerous for our health. It remains to answer the question: how to detect elastic protein intolerance and create the right diet?

Risk factors and groups

Research shows that the occurrence of allergies in an infant is often due to a genetic predisposition. If mom or dad is allergic, then the likelihood that their child will encounter the same problem is 40%. In the case where both parents are susceptible to food allergies, the likelihood of a reaction to a protein in food reaches 80%.

In addition to heredity, the following factors are identified that directly affect the development of allergies in a newborn:

Consumption by the mother of highly allergenic foods during pregnancy. It is recommended to replace milk with fermented milk products, exclude fast food, food with various chemical additives, sweet sodas, etc. Chronic diseases of the mother, especially those that require medication

During pregnancy, it is important to consult with an obstetrician-gynecologist about the compatibility of drugs with pregnancy, monitor the pathology with the help of tests and diagnostics that are safe for the child, and in every possible way prevent the acute course of the disease. A special risk factor is chronic diseases of the cardiovascular system, bronchi and lungs. Diseases suffered during pregnancy: viral and bacterial infections, gestosis. A special risk group are children whose mother was forced to use antibiotics during pregnancy. Fetal hypoxia both during pregnancy and during childbirth

Lack of oxygen leads to disruption of various life processes of the fetus/newborn, including the functioning of the immune system. The child becomes more susceptible to allergic attacks. ARVI and intestinal infections suffered by a child can cause dysbiosis. Diseases disrupt the functioning of the digestive system, which leads to weakened intestinal defenses. As a result, allergens easily and unhindered enter the blood plasma. Frequent replacement of mixtures. Pediatricians recommend not changing the selected adapted feeding formula. If the chosen product suits your baby well, then you should not pay attention to promotions, packaging and advice from other mothers. Eating highly allergenic foods increases the possibility of allergies, which include: dairy products, seafood, eggs and mushrooms, cereals, honey and nuts, citrus fruits, strawberries, tomatoes, carrots and other “bright” vegetables, chocolate.

A special risk group are children whose mother was forced to use antibiotics during pregnancy. Fetal hypoxia both during pregnancy and during childbirth. Lack of oxygen leads to disruption of various life processes of the fetus/newborn, including the functioning of the immune system. The child becomes more susceptible to allergic attacks. ARVI and intestinal infections suffered by a child can cause dysbiosis. Diseases disrupt the functioning of the digestive system, which leads to weakened intestinal defenses. As a result, allergens easily and unhindered enter the blood plasma. Frequent replacement of mixtures. Pediatricians recommend not changing the selected adapted feeding formula. If the chosen product suits your baby well, then you should not pay attention to promotions, packaging and advice from other mothers. Eating highly allergenic foods increases the possibility of allergies, which include: dairy products, seafood, eggs and mushrooms, cereals, honey and nuts, citrus fruits, strawberries, tomatoes, carrots and other “bright” vegetables, chocolate.

Drug allergies: symptoms and treatment

An adverse reaction to medications is nothing more than a drug allergy. What factors influence the occurrence of adverse symptoms?

Medicines allergens

In first place in terms of side effects are antibiotics, such drugs as Aspirin or Tubazid. A sudden allergic reaction is quite common among pharmacy employees or workers in household chemical stores - the frequency of outbreaks is about 25-30%.

Skin rashes from exposure to medicinal vapors or taking medications in women occur in 35% of cases, and anaphylactic reactions to radiocontrast drugs almost double.

The most frequent allergic attacks are observed in females (per one thousand people, drug allergies are diagnosed in 30 women and 14 men), in villages in approximately 20 women and 11 men. Adverse reactions in males are most common between the ages of 30 and 39 years.

A predisposition to chronic skin diseases (atopy) does not mean that an adverse reaction will develop rapidly. Development depends on many factors that coincide by coincidence.

The genetic polymorphic system (HLA) indicates possible hypersensitivity of the body. The presence of viral infections - herpes or sexually transmitted diseases indicates possible risks and accelerated development of the reaction.

Aspirin and non-steroidal anti-inflammatory drugs in some cases provoke acute urticaria, and a group of natural and synthetic chemical compounds (ACE inhibitors) not only cause local swelling of the mucous membrane (angioedema), but also worsen the condition in people with high sensitivity.

Adverse reactions due to drug allergies

Adverse reactions are divided into type B (which does not depend on the amount of dosage), and type A, where the reaction is completely dependent on the dosage.

The main task of the specialist is to determine the reaction when it occurs and divide it into its component parts (differentiation)

It is important that the doctor has sufficient experience to distinguish reaction B from reaction A

If the reaction is caused by a drug allergy, toxins are removed by reducing the dosage of medications (type A). If a drug allergy does not appear due to an increased dose, then it is differentiated into allergic and referred to immunological and non-immunological studies.

It is extremely important to make a clinical assessment of adverse reactions, conduct appropriate skin tests, laboratory tests, if they are possible and will lead to the expected results.

Clinical assessment:

• Identifying adverse reactions at an early stage will make it possible to find out the cause of the drug’s effect on the body, even if the mechanism of the reaction is unclear;
• to provide timely treatment or advice, as well as the ability to identify the presence of and reactions to sulfur-containing antibiotics, as well as reactions to sulfur-containing drugs that do not contain antibiotics or dietary sulfites;
• to identify particularly complex side effects (for example, toxic epidermal necrolysis);
• an assessment is required if it is impossible to do without the addition of additional medications, as well as for the correct selection of non-steroidal anti-inflammatory drugs, especially if there is an allergic reaction to one of the NSAIDs;
• assessment is required when carrying out a set of therapeutic and preventive measures that reduce the body’s sensitivity to allergens (hyposensitization).

Symptoms of drug allergies

The initial symptoms of anaphylaxis can manifest from one system or several:

1. Skin rashes (most people):

Certain areas on the body become red and itchy. An acute course is possible when swelling of the mucous membranes of the skin or subcutaneous tissue develops (angioedema).

1. Airways (40 to 70% of cases):

A hysterical cough, heavy or hoarse breathing (shortness of breath), chest compression, impaired breathing rate, lack of air (dyspnea) are noted. Possible death.

1. Gastrointestinal tract (in 30% of cases):

There are attacks of vomiting, nausea, diarrhea, disruptions in the gastrointestinal tract - bloating, cramping in the stomach.

1. Diseases of the cardiovascular system (cardiovascular):

A rapid heartbeat (tachycardia), a sharp decrease in pressure (hypotension, collapse), loss of orientation (dizziness), and death is possible (in 10% of cases) are noted.

Quickly seeking medical help at the first sign of an allergy can save lives and prevent complications from developing.

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Precautionary measures

It is important for a child with celiac disease to abstain from gluten-containing foods throughout his life. For allergy sufferers - only for the period when the body reacts negatively to protein, that is, for them a gluten-free diet will be temporary

Some people need to follow it for several weeks or months, while others will have to endure up to 1-3 years. In all cases, it is necessary to carefully monitor your diet, excluding foods such as:

• Cereals in the form of pastries, cakes, pastries, cookies, buns and bread
• Semolina, wheat, oatmeal, as well as multigrain ready-made porridges (they usually contain gluten-containing cereals)
• Canned food
• Semi-finished products, sausages, sausages, industrial pates - almost all of them contain gluten as a thickener.
• Sauces, including ketchup and mayonnaise
• Yoghurt and other fermented milk products are allowed only after careful monitoring of composition and tolerance.

Breastfed babies face celiac disease or gluten allergy when introducing complementary foods, because mother's milk contains not only gluten, which comes with the foods of the nursing diet, but also protective factors - antibodies.

If a child receives formula, it is important to make sure that there are no allergies to cow's milk protein and to choose the right basic nutrition. Unfortunately, in most cases, both with an allergy to gluten and with celiac disease, it is necessary to completely eliminate cow's milk protein and replace the standard milk formula with a specialized one (hydrolyzed, soy formula)

Adapted standard formulas and, especially, specialized formulas for children with food allergies (protein hydrolysates, amino acid and soy mixtures) do not contain gluten. But complementary foods, vegetable, fruit and meat purees may contain traces of gluten. It is worth carefully studying the annotations and labels of medicines. Gluten may be included in some medicines.

When introducing cereal complementary foods to children with gluten intolerance, you need to choose gluten-free porridge (rice, buckwheat, corn); from 8-9 months you can introduce millet porridge. Millet is also a gluten-free grain, but it is quite difficult to digest, so it is better to introduce it into the diet later, when the baby is already accustomed to grain-based complementary foods. If mom prefers to cook herself, the cereals must be thoroughly washed, since they are often contaminated with traces of gluten during storage and transportation. Even for a healthy baby, you should not start introducing cereal complementary foods with gluten-containing cereals; you need to make a choice in favor of gluten-free cereals. But it makes no sense to delay the introduction of gluten-containing cereal complementary foods for a long time. It is best for all healthy children to introduce gluten-containing cereals into the diet between 4 and 6 months, after the child has already been successfully introduced to gluten-free cereals. Presumably during this period, the so-called “window of tolerance,” there is the least likelihood of developing an allergy to gluten.