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Clinical features of acute allergic reactions to peanut and tree nuts in children
S H Sicherer1, A W Burks, H A Sampson
1Division of Allergy/Immunology, Department of Pediatrics, Jaffe Food Allergy Institute, Mount Sinai Hospital, Mount Sinai School of Medicine, New York, New York, USA.
Insights
Acute allergic reactions to peanut (PN) and tree nuts (TN) are increasing and often occur upon first exposure. Early diagnosis and education on avoidance and epinephrine treatment are crucial for managing these potentially life-threatening allergies in children.
Area of Science:
- Pediatric Allergy
- Clinical Immunology
- Food Hypersensitivity
Background:
- Peanut (PN) and tree nut (TN) allergies are serious, persistent, and increasingly prevalent conditions in children.
- Limited data exists on the clinical presentation of acute allergic reactions to PN and TN and their co-occurrence.
Purpose of the Study:
- To characterize the clinical features of acute allergic reactions to PN and TN during initial and subsequent accidental ingestions in children.
- To investigate the association between PN and TN allergies.
Main Methods:
- A questionnaire survey, clinical examination, and specific IgE antibody testing were used.
- Patients with confirmed histories of acute allergic reactions (within 60 minutes of ingestion) to PN or TN were included.
Main Results:
- 122 children experienced acute reactions; 34 had allergies to both PN and TN.
- Reactions commonly involved skin (89%), respiratory (52%), and gastrointestinal (32%) systems, often affecting multiple systems.
- Accidental ingestions occurred frequently (55% for PN, 30% for TN) outside the home, with symptoms similar to initial reactions.
Conclusions:
- Acute allergic reactions to PN often occur early in life and can be severe, necessitating emergency treatment.
- Coexisting PN and TN allergies are common, and accidental ingestions are frequent, highlighting the need for prompt diagnosis and education.
- Education on allergen avoidance and the use of self-administered epinephrine is critical for managing these potentially life-threatening food allergies.
Background:
Peanut (PN) and tree nut (TN) allergies are potentially life-threatening, rarely outgrown, and appear to be increasing in prevalence. However, there is relatively little reported about the clinical features of acute reactions to these foods and their potential association.
Objective:
To describe the clinical features of acute reactions during initial and subsequent accidental ingestions of PN and TN among children with a history of at least one acute allergic reaction to these foods.
Design:
Questionnaire survey, examination, and serologic testing for specific IgE antibody of patients with convincing histories of acute reactions (at least one organ system involved within 60 minutes of ingestion) to PN or TN.
Results:
A total of 122 patients (63% males; median age, 8 years at time of study) had acute reactions; 68 had reactions only to PN, 20 only to TN, and 34 to both PN and TN. Of those reacting to TN, 34 had reactions to one, 12 to two, and 8 to three or more different TN, the most common being walnut, almond, and pecan. Initial reactions usually occurred at home (median age, 24 months for PN and 62 months for TN) and were considered to result from a first exposure in 72% of cases. Eighty-nine percent of the reactions involved the skin (urticaria, angioedema), 52% the respiratory tract (wheezing, throat tightness, repetitive coughing, dyspnea), and 32% the gastrointestinal tract (vomiting, diarrhea). Two organ systems were affected in 31% of initial reactions, and all three in 21% of reactions. Thirty-eight of 190 first reactions to PN or TN were treated with epinephrine. Accidental ingestions occurred in 55% of PN-allergic children (average of two accidents per patient with an accidental ingestion) and in 30% of TN-allergic children over a median period of 5.5 years. On average, symptoms after accidental exposure were generally similar to those at initial exposure. Accidents occurred commonly in school but also at home and in restaurants. Modes of accidental ingestion included sharing food, hidden ingredients, cross-contamination, and school craft projects using peanut butter. Eighty-three percent of the children were breastfed, with >90% of the mothers ingesting PN and at least one TN during lactation. Among patients reporting no history of exposure (>60% of patients for each TN), IgE antibodies were found to a particular TN in 50% to 82% of patients and to PN in 100% of patients.
Conclusions:
Acute allergic reactions to PN occur early in life. PN and TN allergic reactions coexist in one third of PN-allergic patients, frequently occur on first known exposure, and may be life-threatening, requiring emergency treatment. Accidental ingestions are common, occur frequently outside of the home, and often require emergency treatment. Consequently, early diagnosis followed by education on avoidance and treatment measures (including self-administered epinephrine) is imperative.