Dietary management of peanut and tree nut allergy: what exactly should patients avoid?

Abstract

Summary Peanut and tree nut allergies are the commonest cause of life‐threatening food‐allergic reactions and significantly affect quality of life in children and their families. Dietary nut avoidance and provision of emergency medication is currently the mainstay of treatment. Nut avoidance has consequences on both quality of life and nutrition. We review the terminology that may cause confusion and lead to unnecessary dietary restrictions. In peanut or tree nut‐allergic children, introduction of specific nuts to which the child is not allergic may improve quality of life and should be considered in patients with multiple foods allergies, vegan or ethnic‐specific diets, in whom nuts are an important source of protein. Nut‐allergic consumers do not just need to avoid foods containing nuts as an ingredient, but also contend with pre‐packed foods which frequently have precautionary allergen labelling (PAL) referring to possible nut contamination. Although the published rate of peanut contamination in ‘snack’ foods with PAL (see Box ) ranges from 0.9–32.4%, peanut contamination in non‐snack items with PAL is far less common. We propose that in some peanut‐allergic patients (depending on history of reactivity to trace levels of peanut, reaction severity, other medical conditions, willingness to always carry adrenaline, etc.), consideration may be given to allow the consumption of non‐snack foods containing PAL following discussion with the patient's (and their family's) specialist. More work is needed to provide consumers with clearer information on the risk of potential nut contamination in pre‐packed food. We also draw attention to the change in legislation in December 2014 that require mandatory disclosure of allergens in non‐pre‐packed foods.

Component‐resolved diagnostics demonstrates that most peanut‐allergic individuals could potentially introduce tree nuts to their diet

“…We are limited to assessing sensitization to these species as challenges were performed only to peanut. We want to emphasize that despite negative species‐specific tests, previously avoided tree nuts should be introduced with caution because some allergens may still remain unknown and could induce severe symptoms …”

A patient‐specific approach to develop an exclusion diet to manage food allergy in infants and children

“…22 It is still unknown whether ingestion of tolerated tree nuts ameliorates development of tolerance to other tree nuts, 23 or whether it prevents development of allergy to the tolerated nut, but it does increase the quality of life of individuals and for vegetarians allows another protein source to be included in the diet. 22 It is still unknown whether ingestion of tolerated tree nuts ameliorates development of tolerance to other tree nuts, 23 or whether it prevents development of allergy to the tolerated nut, but it does increase the quality of life of individuals and for vegetarians allows another protein source to be included in the diet.…”

Outcome of mixed nut biscuit challenges in low‐risk patients who are on tree nut exclusion diet

“…This approach of avoidance affords little diagnostic clarity for peanut allergic individuals and their families as to their allergic status with regard to tree nuts, and the LEAP study demonstrated the benefit of early introduction of peanuts for children at high risk to reduce their likelihood of developing peanut allergy . Precautionary advisory labelling may contribute to anxiety around food choices , and confirming tolerance to selected tree nuts may remove unnecessary dietary restrictions. However, caution must still be exercised regarding cross‐contamination [particularly of snack food items ] and patients may sensibly adhere to a more restricted diet when travelling or remote from medical attention to minimize the risk of inadvertently ingesting a nut to which they are allergic.…”