If your child reacts to nuts, it usually causes a lot of concern, with fear for what may happen in future. However, the reality is usually safer than most people expect, having read the media headlines.
The important steps are to assess whether a genuine allergy to nuts may be likely, to consider whether avoiding nuts may be a safe strategy, and consider arranging expert testing to be absolutely sure that your child has a clear diagnosis and plan in case there are future episodes.
I raise this now because we are headed into the Christmas season, where many traditions offer whole nuts cracked by the fire, nut roast as a vegetarian alternative to roast meats and ‘deluxe’ treats often contain hidden nuts.
Why are nut allergies important?
Nut allergies cause significant worry to their families and may induce an unsafe food allergic reaction. Children with nut allergies may react after eating some nuts, showing skin signs (skin swelling, hives or nettle rash), gastrointestinal upset (normally feeling tingling in the mouth, vomiting or abdominal pain) or nasal symptoms (sniffing, sneezing and running nose). More serious responses include airway (hoarse voice, coughing or voice change), breathing difficulty (breathlessness, wheezing or chest coughing) or drowsiness (feeling dizzy, going pale or losing consciousness). Any of these last more serious symptoms in association with eating nuts are called anaphylaxis and are important to discuss with your doctor. It is these nut reactions that may become unsafe, and around 6 people die from fatal anaphylaxis to eating some type of nut in the UK each year. This may sound alarming, however someone with food allergy is just as likely to die from it as be struck by lightening! It is a very very rare event.
However, some nut allergies are less serious. For instance, people with hay fever have immune systems that recognise pollen proteins during the spring or summer. Unfortunately, the immune system of these patients can also find pollen-like-proteins in nuts. This means that when the nut is swallowed, there may be an uncomfortable feeling of itching in the mouth, scratching sensitivity down the throat or lip swelling, which may show that the body thinks that pollens are being eaten! This is called Pollen Food Syndrome, and can also cause an itchy mouth with carrot, celery, uncooked apple, peach or cherry. All of these oral and digestive responses are safely treated with antihistamine, because anaphylaxis is so very rare with Pollen Food Syndrome. This is because the pollen-type proteins are broken down in the stomach acid and are less likely to be absorbed in appreciable quantities which become unsafe.
Fortunately, blood testing can distinguish clearly between pollen food syndrome and unsafe nut allergies, which is why an expert diagnosis can give better reassurance than a high-street-allergy test. This forms an important part of testing, along with skin prick testing and modified skin prick testing to the nuts. themselves where possible.
Are all nuts the same?
Although this make it sound like the immune system is easily fooled, it is pretty good really and reliably spots the difference between different types of nut. For instance, children may be allergic to peanut, however they may be safe to eat tree nuts (which include cashew, almond, hazelnut, brazil nut and walnut).
This is important, because peanut allergy is the most common nut allergy in the UK with around 0.5-1% of children showing objective signs of allergy on peanut challenge. However, the next four most common nut allergies in childhood are around half as common; with cashew, hazelnut, walnut and sesame seed allergies forming the majority of the other instances.
It is important to spot when children may be able to tolerate a proportion of the different nuts because there is a good chance that if we start children eating nuts when they are young, we can protect against their developing allergies to these other tree nuts as they get towards school age. We know this from the LEAP Study and the EAT Study which showed that the more peanut is eaten before the development of peanut allergy as young children, the more protected children are from developing peanut allergy.
Can my child react to nuts from across a room?
The proteins in nuts do not easily travel by air. Studies have shown that cooking peanut does not release ‘peanut protein vapours’ above. The only risk of being in a room with a nut, is if the nut is brought closer through inadvertent cross contamination, and particularly if it is introduced into food or on to items that may go in your child’s mouth. This is more commonly a risk when eating dusty whole nuts, like freely eating peanuts by the handful. If there is a young peanut allergic toddler at home, adults who eat handfuls of peanuts over the sofa or child’s play mat expose the young child to the risk of inadvertently putting peanut particles in their mouth.
However, it is usually safe for a child to touch the nut to which they are allergic, so long as the protein does not end up in their mouth. At the very most, there may be some mild redness where the nut touched, and this may become angry or red if the nut was rubbed on eczema which should be avoided.
There was a randomised study to show children that it can be safe to coexist or even hold one of the nuts to which they are allergic. The study team gave allergic children nuts to hold to help reduce their anxiety, so that they could start to understand whether the need to be fearful of the nuts themselves, or whether they should understand better simply to avoid eating them and be careful to ask about ingredients.
Can my child eat nuts when my other child is allergic?
With safe and careful practices at home, it can be safe for a young child to start eating peanut regularly in their diet, whilst the older child may still have peanut allergy and need to avoid cross contamination.
In practice, I advise;
- Ensuring the young baby eats their peanut in their own baby bowl with their own spoon
- Using separate cleaning cloths to reduce the chances of cross contaminating peanut across onto to the cutlery and culinary tools for the older family members
- Not relying on dishwashers to always clean off all protein deposits
- Ensuring that an adult keeps an eye on where peanut is eaten in the house; I would advise not to eat nuts over the sofa, play toys or over where the allergic child eats if there is a known risk of allergy to that same type of nut.
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What is peanut immunotherapy?
If your child is very sensitive to peanut and you are concerned that eating a tiny amount may raise an unsafe allergic reaction, then there are new peanut allergy treatments being licensed over this next year.
The UK is currently licensing a commercial peanut product which enables tiny amounts of peanut protein to be given every day in very carefully graded amounts, starting from only a few milligrams, in order to lessen the sensitivity of the allergy. After months of treatment with regular in hospital assessments to increase the doses of peanut, it is possible for some children to start eating as much as a whole peanut every day, although it is still recommended that they do not eat peanut as part of their normal diet. If treatments like this are of interest, it is important to undergo a thorough assessment and discussion before considering the full programme.
How does testing and planning help?
We are able to provide accurate testing, to enable;
- Safe guidance on which exact nuts and seeds to avoid
- Indicate whether small amounts may be safe
- Recommend how much should be eaten to protect from developing an allergy
- Treat asthma and eczema to help ensure safety in case of accidental nut ingestion
- Provide emergency reaction medication in case of accidental reaction
- Share treatment plans between carers and school professionals to ensure your child is safe in all environments
- Discuss the potential benefits of peanut immunotherapy
Do not hesitate to get in touch to ensure your child is safe and confident around nuts.