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Abrams EM, Sicherer SH. Tree nut introduction in a peanut-allergic child: To eat, to screen, or to avoid? Pediatr Allergy Immunol 2022; 33:e13669. [PMID: 34553798 DOI: 10.1111/pai.13669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/07/2021] [Accepted: 09/14/2021] [Indexed: 02/03/2023]
Abstract
There is no defined standard of care around tree nut introduction in a peanut-allergic child, and the role of screening prior to tree nut introduction is controversial. There is some evidence that peanut-allergic children are at increased risk of tree nut allergy, with approximately 23-68% of children with co-existent peanut/tree nut allergy. In some studies, it has been shown that tree nut allergy in children has the potential to be a severe allergy. However, this appears to be age-specific as infant anaphylaxis in general tends to be milder, and there has been no fatality reported on the first ingestion of an allergen in infancy. Familial hesitancy has been identified as a possible condition for undertaking screening tests prior to allergen introduction. Indeed, there has been limited evidence that caregiver hesitancy may exist in peanut-allergic families with tree nut introduction. However, pre-emptive screening has the potential to overdiagnose tree nut allergy and delay introduction (which could paradoxically increase risk). As a result, the decision is best made in the context of shared decision-making and patient preference-sensitive care.
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Affiliation(s)
- Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada.,Department of Pediatrics, Division of Allergy and Immunology, University of British Columbia, Vancouver, BC, Canada
| | - Scott H Sicherer
- Elliot and Roslyn Jaffe Food Allergy Institute, Division of Allergy and Immunology, Kravis Children's Hospital, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Midun E, Radulovic S, Brough H, Caubet JC. Recent advances in the management of nut allergy. World Allergy Organ J 2021; 14:100491. [PMID: 33510829 PMCID: PMC7811165 DOI: 10.1016/j.waojou.2020.100491] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 11/02/2020] [Accepted: 11/03/2020] [Indexed: 11/25/2022] Open
Abstract
Peanut/tree nut allergy is common and has been associated with particularly severe reactions. Epidemiological data have shown that the prevalence ranges between 0.05% and 4.9% for tree nut and between 0.5% and 3% for peanut. These large variations can be explained by differences in the age of included patients and the geographical region. In addition, the food consumption modality (ie, raw versus roasted) plays a major role, as heat treatment has the capacity to modify the allergenicity of nuts and legumes. Nut allergies tend to persist into adulthood and consequently have a high impact on quality of life. Recently, it has been demonstrated that a significant proportion of nut allergic patients are able to tolerate other nuts. As opposed to the avoidance of all nuts, this approach is currently proposed in several tertiary allergy centers. However, diagnosis of nut allergy is particularly difficult due to co-sensitization leading to high rate of false positive skin prick tests and/or specific IgE to whole allergen extracts. The use of component resolved diagnosis leads to major improvement of diagnosis, particularly to distinguish between primary and secondary nut allergies. The basophil activation test has been suggested to be useful but is still used mainly as a research tool. Thus, diagnosis remains mainly based on the oral food challenge, which is considered as the gold standard. Regarding treatment, avoidance remains the cornerstone of management of nut allergy. Oral immunotherapy is increasingly proposed as an alternative management strategy.
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Key Words
- Component-resolved diagnostic, CRD
- Cross reactivity
- Double-blind, placebo-controlled, food challenge, DBPCFC
- Food allergy
- Lipid transfer protein, LTP
- Oral allergy syndrome, OAS
- Oral food challenge, OFC
- Oral immunotherapy
- Oral induction tolerance, OIT
- Pathogenesis related protein type 10, PR-10
- Peanut
- Platelet-activating factor, PAF
- Pollen-food syndrome, PFS
- Precautionary Allergen Labels, (PAL)
- Skin prick test, SPT
- Tree nut
- Tree nut, TN
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Affiliation(s)
- Elise Midun
- Pediatric Allergy Unit, University Hospitals of Geneva and University of Geneva, Rue Willy Donzé 6, 1205 Geneva, Switzerland, University Lyon 1 Claude Bernard, 43 Boulevard Du 11-Novembre-1918, 69100, Villeurbanne, France
- Corresponding author.
| | - Suzana Radulovic
- Paediatric Allergy Group, Department of Women and Children's Health, King's College London, London, United Kingdom, Paediatric Allergy Group, Peter Gorer Dept of Immunobiology, School of Immunology & Microbial Sciences, King's College London, Guys' Hospital, London, United Kingdom, Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, United Kingdom
| | - Helen Brough
- Paediatric Allergy Group, Department of Women and Children's Health, King's College London, London, United Kingdom, Paediatric Allergy Group, Peter Gorer Dept of Immunobiology, School of Immunology & Microbial Sciences, King's College London, Guys' Hospital, London, United Kingdom, Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, United Kingdom
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, University Hospitals of Geneva and University of Geneva, Rue Willy Donzé 6, 1205, Geneva, Switzerland
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Brough HA, Caubet JC, Mazon A, Haddad D, Bergmann MM, Wassenberg J, Panetta V, Gourgey R, Radulovic S, Nieto M, Santos AF, Nieto A, Lack G, Eigenmann PA. Defining challenge-proven coexistent nut and sesame seed allergy: A prospective multicenter European study. J Allergy Clin Immunol 2019; 145:1231-1239. [PMID: 31866098 DOI: 10.1016/j.jaci.2019.09.036] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 09/04/2019] [Accepted: 09/26/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Peanut, tree nut, and sesame allergies are responsible for most life-threatening food-induced allergic reactions. Rates of coexistent allergy between these foods have been from mostly retrospective studies that include only a limited number of tree nuts or were not based on oral food challenges. OBJECTIVE The Pronuts study is a multicenter European study (London, Geneva, and Valencia) assessing the challenge-proven rate of coexistent peanut, tree nut, and/or sesame seed allergy. METHODS Children aged 0 to 16 years with at least 1 confirmed nut or sesame seed allergy underwent sequential diagnostic food challenges to all other nuts and sesame seed. RESULTS Overall, the rate of coexistent peanut, tree nut, and sesame seed allergy was 60.7% (n = 74/122; 95% CI, 51.4% to 69.4%). Peanut allergy was more common in London, cashew and pistachio nut allergies were more common in Geneva, and walnut and pecan allergies were more common in Valencia. Strong correlations were found between cashew-pistachio, walnut-pecan, and walnut-pecan-hazelnut-macadamia clusters. Age (>36 months) and center (Valencia > Geneva > London) were associated with an increased odds of multiple nut allergies. By pursuing the diagnostic protocol to demonstrate tolerance to other nuts, participants were able to introduce a median of 9 nuts. CONCLUSION We found a higher rate of coexistent nut and sesame seed allergies than previously reported. Performing sequential food challenges was labor intensive and could result in severe allergic reactions; however, it reduced dietary restrictions. Age was a significant predictor of multiple nut allergies, and thus the secondary spread of nut allergies occurred in older children.
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Affiliation(s)
- Helen A Brough
- Paediatric Allergy Group, Department of Women and Children's Health, King's College London, London, United Kingdom; Paediatric Allergy Group, Peter Gorer Dept of Immunobiology, School of Immunology & Microbial Sciences, King's College London, Guys' Hospital, London, United Kingdom; Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, United Kingdom.
| | - Jean-Christoph Caubet
- Department of Pediatrics Gynecology and Obstetrics, Medical School of the University of Geneva, University Hospitals of Geneva, Geneva, Switzerland
| | - Angel Mazon
- Unit of Pediatric Allergy and Pneumology, Children's Hospital La Fe, Institute of Health Research La Fe, Valencia, Spain
| | - Diab Haddad
- St Peter's Hospital, Chertsey, United Kingdom
| | - Marcel M Bergmann
- Department of Pediatrics Gynecology and Obstetrics, Medical School of the University of Geneva, University Hospitals of Geneva, Geneva, Switzerland
| | - Jacqueline Wassenberg
- Unit of Pediatric Allergy and Rheumatology, Department of Pediatrics, University Hospital of Lausanne, Switzerland
| | - Valentina Panetta
- L'altrastatistica srl, Consultancy & Training, Biostatistics Office, Rome, Italy
| | - Rosalynd Gourgey
- Paediatric Allergy Group, Department of Women and Children's Health, King's College London, London, United Kingdom; Paediatric Allergy Group, Peter Gorer Dept of Immunobiology, School of Immunology & Microbial Sciences, King's College London, Guys' Hospital, London, United Kingdom; Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, United Kingdom
| | - Suzana Radulovic
- Paediatric Allergy Group, Department of Women and Children's Health, King's College London, London, United Kingdom; Paediatric Allergy Group, Peter Gorer Dept of Immunobiology, School of Immunology & Microbial Sciences, King's College London, Guys' Hospital, London, United Kingdom; Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, United Kingdom
| | - Maria Nieto
- Unit of Pediatric Allergy and Pneumology, Children's Hospital La Fe, Institute of Health Research La Fe, Valencia, Spain
| | - Alexandra F Santos
- Paediatric Allergy Group, Department of Women and Children's Health, King's College London, London, United Kingdom; Paediatric Allergy Group, Peter Gorer Dept of Immunobiology, School of Immunology & Microbial Sciences, King's College London, Guys' Hospital, London, United Kingdom; Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, United Kingdom; Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
| | - Antonio Nieto
- Unit of Pediatric Allergy and Pneumology, Children's Hospital La Fe, Institute of Health Research La Fe, Valencia, Spain
| | - Gideon Lack
- Paediatric Allergy Group, Department of Women and Children's Health, King's College London, London, United Kingdom; Paediatric Allergy Group, Peter Gorer Dept of Immunobiology, School of Immunology & Microbial Sciences, King's College London, Guys' Hospital, London, United Kingdom; Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, United Kingdom
| | - Philippe A Eigenmann
- Department of Pediatrics Gynecology and Obstetrics, Medical School of the University of Geneva, University Hospitals of Geneva, Geneva, Switzerland
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Elizur A, Appel MY, Nachshon L, Levy MB, Epstein-Rigbi N, Golobov K, Goldberg MR. NUT Co Reactivity - ACquiring Knowledge for Elimination Recommendations (NUT CRACKER) study. Allergy 2018; 73:593-601. [PMID: 29127694 DOI: 10.1111/all.13353] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Ambiguities exist regarding the diagnosis of tree-nut allergy, necessitating either their elimination or the performance of oral food challenges (OFCs). OBJECTIVE To examine the coincidences of allergies among tree-nuts and improve diagnostic testing to minimize the need for OFC. METHODS Eighty-three patients prospectively evaluated for walnut, pecan, cashew, pistachio, hazelnut, and almond allergy. A history of previous reactions was obtained, and standardized skin prick tests (SPTs) using finely ground tree-nut solution and basophil activation tests (BAT) were performed. Patients underwent OFC for each tree-nut they eliminated and to which a reaction in the previous 2 years was not documented. RESULTS While most patients were sensitized to 5-6 tree-nuts, over 50% were allergic to only 1-2 tree-nuts. The highest rate of allergy in sensitized patients was observed for walnut (74.6%) and cashew (65.6%). The rate of co-allergy for most tree-nuts was <30%. Two-thirds of walnut- and cashew-allergic patients were also allergic to pecan and pistachio, respectively, while all pecan- and pistachio-allergic patients were allergic to walnut and cashew, respectively. Receiver-operating characteristic analysis for SPT and BAT was tree-nut dependent and yielded area under the curve (AUC) values ranging from 0.75 to 0.94. Knowledge of coincident allergies in these pairs along with the combination of SPT and BAT correctly distinguished allergic from tolerant patients for walnut (87%), pecan (66%), cashew (71%), and pistachio (79%). CONCLUSION The data presented here should assist in differentiating between allergic and tolerant patients, decrease the need for OFC, and allow for appropriate elimination recommendations.
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Affiliation(s)
- A. Elizur
- Institute of Allergy, Immunology and Pediatric Pulmonology; Assaf-Harofeh Medical Center; Zerifin Israel
- Department of Pediatrics; Sackler Faculty of Medicine; Tel Aviv University; Zerifin Israel
| | - M. Y. Appel
- Institute of Allergy, Immunology and Pediatric Pulmonology; Assaf-Harofeh Medical Center; Zerifin Israel
| | - L. Nachshon
- Institute of Allergy, Immunology and Pediatric Pulmonology; Assaf-Harofeh Medical Center; Zerifin Israel
| | - M. B. Levy
- Institute of Allergy, Immunology and Pediatric Pulmonology; Assaf-Harofeh Medical Center; Zerifin Israel
| | - N. Epstein-Rigbi
- Institute of Allergy, Immunology and Pediatric Pulmonology; Assaf-Harofeh Medical Center; Zerifin Israel
| | - K. Golobov
- Institute of Allergy, Immunology and Pediatric Pulmonology; Assaf-Harofeh Medical Center; Zerifin Israel
| | - M. R. Goldberg
- Institute of Allergy, Immunology and Pediatric Pulmonology; Assaf-Harofeh Medical Center; Zerifin Israel
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Eigenmann PA, Lack G, Mazon A, Nieto A, Haddad D, Brough HA, Caubet JC. Managing Nut Allergy: A Remaining Clinical Challenge. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 5:296-300. [PMID: 27793601 DOI: 10.1016/j.jaip.2016.08.014] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 07/16/2016] [Accepted: 08/22/2016] [Indexed: 11/16/2022]
Abstract
Peanut and tree nut allergies have become a public health problem over the last 2 decades. The diagnostic procedure relies on a suggestive history, as well as on evidence of sensitization (skin prick testing and/or specific IgE blood testing), followed in selected cases by a food challenge. Standard IgE tests may be positive to more than 1 nut, due to cross-reactivity (allergens common to several nuts) or cosensitivity (frequently associated positive test results without cross-reactivity). Thus, many patients with a peanut or a tree nut allergy avoid all nuts, relying on positive test results without clinical evidence of reactivity. In addition, coexisting pollen sensitivity may add to diagnostic uncertainty due to potential cross-reactivity between pollens and nuts. In this article, we discuss challenges in diagnosis and clinical management of peanut and tree nut allergy related to cross-reactivity and cosensitization, as well as the avoidance of nuts tested positive to reduce the risk of reactions by cross-contamination. Studies to provide more accurate characterization of genuine clinically relevant cross-reactivity or cosensitivity to multiple nuts are needed.
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Affiliation(s)
- Philippe A Eigenmann
- Pediatric Allergy Unit, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland.
| | - Gideon Lack
- King's College London, Medical Research Council and Asthma UK Centre in Allergic Mechanisms of Asthma, Division of Asthma, Allergy and Lung Biology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Angel Mazon
- Children's Hospital La Fe, Pediatric Pulmonology and Allergy Unit, Instituto de Investigacion La Fe, Valencia, Spain
| | - Antonio Nieto
- Children's Hospital La Fe, Pediatric Pulmonology and Allergy Unit, Instituto de Investigacion La Fe, Valencia, Spain
| | - Diab Haddad
- St Peter's Hospital, Chertsey, United Kingdom
| | - Helen A Brough
- King's College London, Medical Research Council and Asthma UK Centre in Allergic Mechanisms of Asthma, Division of Asthma, Allergy and Lung Biology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
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