Children With Nut Allergies: One Size Does Not Fit All

Pam Harrison

December 24, 2014

It is not "one size fits all" in the management of peanut and tree nut allergies, a comprehensive review suggests, but rather, treatment plans need to be individualized for children allergic to peanuts and/or tree nuts to meet their nutritional needs and still keep children safe from allergic food reactions.

The review was published online November 28 in Clinical and Experimental Allergy. Helen Brough, MD, from Guy's and St. Thomas' National Health Service Foundation Trust, London, United Kingdom, and colleagues tried to synthesize current evidence on how best to manage a child with limited allergies to nuts as well as what to do with prepackaged foods that carry precautionary allergy labeling (PAL).

"What we are trying to do is make sure healthcare professionals are well informed, because if they are in a better position of information and knowledge, they are going to be better able to provide information to parents," coauthor Paul Turner, MD, from Imperial College London, United Kingdom, told Medscape Medical News.

"What might be appropriate for one child to eat might not be the case for the next child, and it's really important at a healthcare professional level to be educated because it's far more difficult to undo bad education than it is to give the correct facts in the first place."

"In peanut or tree nut allergic children, introduction of specific nuts to which the child is not allergic may improve quality and life and should be considered in patients with multiple food allergies, vegan or ethnic-specific diets, in whom nuts are an important source of protein," the researchers write.

They also point out that healthcare providers may need to clarify which nuts are potentially allergenic and which "nuts" are not.

"It is common for some people to restrict foods whose name contains the world 'nut'," the authors suggest, including nutmeg, butternut squash, and coconuts, none of which cause allergies.

Peanut and tree nut allergies may be the most common cause of life-threatening food allergic reactions, they add, but a peanut is actually a legume and is botanically quite distinct from other nuts, which grow on trees.

Moreover, it is often assumed that a child with a history of a significant reaction to a very small amount of peanut has a higher risk for future anaphylaxis.

"[H]owever, this does not appear to be the case," the authors write, "[and the] severity of future peanut and tree nut allergic reactions is difficult to predict."

Whether or not nut avoidance is helpful in terms of preventing nut allergies is also under question.

For example, the prevalence of peanut allergy has increased significantly in both the United Kingdom and the United States during recent years, despite the fact that organizations such as the American Academy of Pediatrics have long recommended that children with a parent or a sibling with an atopic disease avoid nuts until the age of 3 years.

"These observations...imply that nut avoidance may not be helpful as a means of primary prevention," the researchers write.

PAL and Cross Contamination

Then there is the whole issue of PAL.

As the authors point out, the absence of PAL does not indicate a food is free of potential cross-contaminants.

In one study of more than 500 prepackaged foods, investigators found there was no significant difference in the frequency of significant peanut contamination between foods with a PAL and those without a PAL.

In contrast, recent data from the United Kingdom indicate that very few allergic reactions are caused by traces of allergens in prepackaged food.

"Most reactions are due to food eaten from takeaways or food produced by others, and not prepackaged food," Dr Turner said. "And those due to prepackaged food are usually the result of someone misreading the label where the actual food was in the ingredients."

Sources of food that can contain sufficient peanut to trigger a reaction can be classified as "snack" foods, the researchers indicate.

Snack foods that could trigger such a reaction include:

  • chocolates and chocolate-based foods such as chocolate spreads,

  • cookies/biscuits,

  • muesli bars/cereal bars/trail bars/dried fruit bars/nutrition bars,

  • baked goods/baking mixes (cakes, pastries),

  • sweets and candies,

  • ice cream, and

  • speciality breads.

These are the foods children with peanut or tree nut allergies really need to avoid, the researchers emphasize.

In contrast, significant peanut contamination has not been documented in other categories of food, including breakfast cereals, frozen desserts, or pasta.

"It is clear that many allergic individuals already ignore PAL on pre-packaged foods and do not appear to experience reactions as a consequence," the authors observe.

"[So] consideration should be given to allow the consumption of non snack foods containing PAL [in some peanut allergic patients,] following discussion with the patient's specialist."

Much More Complex

Carina Venter, PhD, from the University of Portsmouth, United Kingdom, told Medscape Medical News that dietary advice is now much more complex than it was before.

"When I started working in allergies 10 years ago, advice was very simple. Everybody was just told to avoid the foods they were allergic to, so we used to say, if you are allergic to any one nut, avoid all nuts," Dr Venter said.

However, allergy specialists now know that people become tolerant to baked forms of foods to which they are allergic, she added.

For example, people can eat cake before they can have a boiled or scrambled egg, or they can tolerate waffles before they can tolerate a glass of milk.

"It's the same with nuts," Dr Venter added. "We've come to realize that many people could be allergic to one nut or a few nuts, but safely eat the other nuts they are not allergic to.

"And enabling a child to eat cashew nuts, for example, to which they are not allergic, varies up their diet in terms of so many other foods they can eat and helps them to interact socially so much more easily."

One author reports grants from 70 food companies. One author reports receiving lecture fees from Sodilac, Novartis, Nestlé Nutrition, GlaxoSmithKline, and the Serono Symposia International Foundation and has stock/options in DBV Technologies. The remaining authors and Dr. Venter have disclosed no relevant financial relationships.

Clin Experimental Allergy. Published online November 28, 2014. Abstract

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