Nut allergy - The Basics
Table of Contents
Allergic to nuts? Information is vital.So your child or you yourself have reacted to nuts. You are in good company, and you should be able to get help of all sorts to have some idea of how serious the problem is and to prevent disaster if that is a risk (it probably is, at least to some extent), and most importantly to fight disaster effectively if it seems to be occurring. Few people indeed die from allergy to nuts, but those few do die, so the danger has to be taken seriously.
Here is some information to help. Other sources of information are:
Avoiding nuts is more easily said than done. In fact if you are allergic to nuts it is impossible in practice to guarantee that you will never eat anything containing nuts you are allergic to.
Fortunately there is a highly effective treatment: adrenaline. But adrenaline needs to be given as an injection or inhalation, and is dangerous if used incorrectly. If you need to have adrenaline available for yourself or someone in your family, it is important that you and anyone else who may have to give the adrenaline should be properly trained.
To find out more about anaphylaxis, click here.
Effects of nut allergy which you or the patient may noticeNut allergy can produce:
Of the small number of deaths due to nut allergy which happen each year (a handful or thereabouts in the UK each year), most seem to happen in teenagers and people in their twenties, perhaps because they take more risks, but also for reasons we don't understand. Certainly the risk in these age groups is a lot higher than in pre-teens. Even so, deaths from accidents are far more common than deaths from nut allergy in this age range.
Beyond the teens the risk of having a reaction in any one year seems to go down for most people, but if you have a serious anaphylactic reaction the risk of dying from it seems to increase with age. This is probably because the heart and blood vessels can't cope with such a reaction nearly so well as in the young.
But for all age groups nuts are a very minor overall risk to life compared to other everyday risks. The balance of opinion is that the risk from nuts is one we can do something about and that we should therefore do so.
Though we have a probably fairly good idea about the risk of death from nut allergy in the whole population, at the moment we don't know enough to be precise about the size of the small risk in someone who is already known to be allergic to nuts. The reason is that we are not sure enough yet about how many people have nut allergy, so we can't work out the fraction who have fatal reactions.
Will my child grow out of nut allergy?Until recently, surveys done some years after diagnosis were not encouraging. Although a few children did seem to grow out of nut allergy, the general consensus was that it seemed to be a life-long condition. Recently, several groups of doctors have discovered that the picture does not seem to be quite so bleak, especially for young children. There do seem to be quite a lot of children who do grow out of nut allergy after all. This question is therefore getting a lot of interest from researchers.
The biggest risk period seems to be in the teens and young adulthood, perhaps because young people of this age become more independent, are no longer protected by parents so much of the time, and may not be so strict about keeping their treatment with them all the time.
Beyond the teens and twenties the impression is that the risk of accidentally eating nuts becomes smaller again as we adopt a less riksy and variable lifestyle. But older people who do get anaphylaxis are more likely to die of it. One reason for this is probably that heart disease and hardening of the arteries make us more vulnerable as we get older.
Age is not the only thing which has a big effect on the risk. For example if you have asthma your riks is greater, because if you get anaphylaxis the asthma is prone to become very bad as part of this. People with asthma who get anaphylaxis need to be particularly careful to use preventive drugs for their asthma to cut this risk.
A mother from California e-mailed us:
"Is there any group looking to ban peanuts on airlines? I am afraid to fly with my son.
On one flight a drunk woman became upset when the stewardess requested she refrain from eating her peanuts until we landed because of my son's allergies. I have called the airline every time we fly but unfortunately, they never substitute for peanuts. I am looking for a group to help me lobby to remove peanuts from all flights."
According to the Times newspaper Sep 3 1998, p 17, col 1, the US Government Department of Transportation has told all large American airlines that they must set aside a "peanut-free zone" when requested to do so by passengers with medically documented peanut allergies. If they do not stop serving peanuts on the flight, the minimum for the "peanut-free zone" is the row of seating with the passenger plus the rows in front and behind. This is in conformity with a law passed in 1986 that guarantees access to planes for the disabled.
Plane Nuts! The story of the airline peanut- Air Travel- Date: 12 August 1998 (http://airtravel.miningco.com/library/weekly/aa081298.htm) is a website which argues that this decision by the US Government Department of Transportation (DOT ) is wrong. Clearly the author does not know anyone with serious nut allergy. The site invited votes for and against the DOT ruling.
If you have some other medical conditions such as high blood pressure, or an abnormal heart rhythm, or narrowing of the coronary arteries, or if you are treated with some other medicines such as medicines for depression, special caution is needed with adrenaline, and a specialist should advise you.
If your child gets just a few itchy swollen spots near the lips and the reaction is not getting worse, by all means have the injection at the ready and make sure you can get help quickly if things deteriorate, but if they are not deteriorating, why inject?
On the other hand, if your child is lying unconscious, with obvious difficulty in breathing, it could already be too late. So there is a right time to give adrenaline (epinephrine) and your judgement as a nonmedical person needs to be be good enough to get this right.
Our recommendation is the "3D RULE" :
Quite often they are not, but unfortunately many children and adults who are allergic to one kind of nut also become allergic to other kinds. This includes not only peanuts, almonds, brazil nuts, cashew nuts, hazel nuts, pistacio nuts, walnuts and pecan nuts, but also in rather fewer people coconut, sesame seed, poppy seed, sunflower seed, and pine kernels.
The next 2 paragraphs were added 23rd Jan 2001 in response to numerous emails..
It is surprising that allergy to peanuts does go together with allergy to tree nuts, because peanuts are closely related to peas and beans and not closely at all to tree nuts. Nevertheless allergies seem to ignore the botanists and their classifications in this. We don't know why. If you are allergic to peanuts you're far from certain to be allergic to the other nuts, but the risk of that is far higher than in people who don't have peanut allergy. The same is true the other way round. If you are allergic to tree nuts, you are more likely to become allergic to peanuts. Skin and blood tests often show allergy to more kinds of nuts than people suspect before the test.
Perhaps just as surprisingly, some things which are called nuts or look like nuts don't particularly cause trouble in people with nut allergy. Edible chestnuts (Spanish chestnuts, marrons) are one example. Although they are called nuts and although they do cause allergic reactions in some people (especially people with latex allergy), they seem to leave people with other nut allergies in peace. Nutmeg is another very good example I'm often asked about. I have never known it cause trouble in people with nut allergy, and if it does cause the anaphylactic kind of allergy at all, it seems at the moment as if this must be very rare.
Sesame seed is particularly difficult to avoid with certainty as the seeds are so small and may fall off bakery products. It is the main ingredient of tahini (tehina, tchina), which is in turn an ingredient of other foods, for example houmous (various other spellings are used, e.g. hummus). We would like e-mail with any useful information from people who have problems with sesame seeds, poppy seed, sunflower seed, and pine kernels. It is strange that all these kinds of nuts and seeds cause problems in the same people, because peanuts, almonds and coconuts, for example, come from plants which are not closely related. The fact is that one person may be allergic to any or all of them.
Best to avoid all nuts, and to be suspicious of sesame seeds, poppy seed, sunflower seed, and pine kernels.
A fallacious argument goes as follows. "My child has a brother or sister with nut allergy and has a positive skin test. Because nut allergy may run in families to some extent there may be a reaction to nuts, and I cannot be absolutely sure that the first reaction will not be fatal. Therefore my child should have an adrenaline kit." This sounds logical, but is not.
Firstly, without question giving adrenaline kits on this basis could double the number of children carrying adrenaline. But the additional kits would be given to children with a much lower risk than those given adrenaline at present. It is highly possible (in my estimate virtually certain) that this would result in more harm than good (in my view much more harm than good). Inevitably some of the kits end up being used inappropriately. The practical and psychological burden from an adrenaline kit is far from negligible for the family, for the school, and for other carers.
Secondly, skin tests (or blood tests) are far from absolutely reliable. A positive result by no means guarantees that the child will react when it eats nuts. In children with negative test results we also cannot be absolutely sure there will not be a reaction and that the first reaction will not be fatal. In fact we can't be absolutely sure of anything in this area, and logically we would soon be in the ludicrous position of giving an adrenaline kit to every child in the world.
The flaw in the argument lies in the word absolutely.
In truth we cannot be absolutely sure of anything where health is concerned, and trying to achieve such certainty is pointless and even dangerous. You and I cannot be absolutely sure we won't be struck dead by lightning tomorrow, be diagnosed as having leukaemia next week or even succumb to nut allergy the next time we eat nuts ourselves even if we have not been allergic to them before. But no sensible person goes around wearing a lightning conductor or taking routine action against the other possibilities. We live with mostly larger risks, such as those of being killed in a road accident.
Risk is always present in life. Being alive means living with risk. The sensible question is whether a health risk and the benefit of treatment are large enough to justify the inconvenience, risk and expense of treatment. It is not at all a matter of absolute principles, but of the size of the risk and then the size of the beneficial and harmful effects of the treatment.
We do not have even remotely accurate ideas about the size of these risks and benefits in children who have never reacted. The inaccurate ideas we do have suggest that adrenaline is NOT appropriate for brothers or sisters of nut-allergic children. Future research could fill in our knowledge. Right now we must act on the knowledge we have now. The risk that a first reaction will be fatal is not non-existent, but it is generally agreed to be extremely small, and smaller than many other risks in life.
It is a sound principle to use medical treatments only where there is positive evidence that they are appropriate. This is not the case with the issuing of adrenaline kits for children who have never had a reaction, whatever may have happened to their brothers or sisters.
Unrefined or 'cold pressed' peanut oil, or 'gourmet oil' with peanut material added for flavour are dangerous.
'Vegetable oil', according to our information, will not intentionally contain peanut oil because peanut oil is considerably more expensive. Some is produced with machinery also used for peanut oil and may thus be contaminated with it. This seems unlikely to be important.
Although refined oil does not seem to cause reactions, it seems conceivable that ultra-minute traces of peanut protein in it, insufficient to cause symptoms, might still sensitise someone, or worsen the sensitivity. This is just a theoretical possibility, and there is no proof that it happens. A very poor piece of evidence is the widely expressed view that peanut oil in nipple creams made for breastfeeding mothers may be the reason for the increase in nut allergy. However, if that view were right, it would exactly show that oil which did not cause symptoms did sensitise.
British Medical Journal 12 April 1997.
This is an interesting idea, but does not seem to fit all the facts. Other allergies such as hayfever have also increased, but pollen concentrations have not, for example. There are clearly other reasons why allergies have increased. It does not seem that the apparent increase in nut allergy parallels a historical change in the sales of Kamilosan.
Nevertheless, it seems sensible to avoid such creams which contain peanut oil, and the new version contains no nut oil.
The French also have several quite different names. Harrap's dictionary gives:
Here is the same in German - "Ich bin allergisch gegen Nüsse".
In Spanish the word for peanut is cacahuete; the word for peanut butter is manteca de cacahuete or manilla; for peanut oil: aceite de cacahuete. These words are used throughout Mexico and Latin America. However, in Spain, they also say, "frutas secas" (as in dried fruits, but this refers to nuts). In addition, in both Spain and Latin America the word "nuez" (nut) is used. I am indebted to Sherree Colvin for this information. Humbert Hernandez from Gibraltar adds that in Andalucia (south of Spain) the word "avellana" is commonly used to denote peanuts, even though it actually means hazel nut.
In Pakistan, English speakers also say 'dry fruits' to refer to nuts. Surely this will be a literal translation of an Urdu expression.Dutch names (identical spelling in Flemish):
N.B. if you are not familiar with Dutch pronunciation, don't try to
predict it from English or German. E.g. 'apenoot' is absolutely not
pronounced the way you would expect from English. It has three syllables, the
'a' sound is more open than the 'a' in 'father' in English, the 'e' is
pronounced as a neutral vowel, and the 'oo' is like the 'o' in 'no' in
English. Ask a Dutch person.
It is obvious that other languages are likely to have similar complications. Get your information from a native speaker and a large dictionary (go to a public or university library), don't assume that they have remembered to tell you all the names, and don't assume you can correctly pronounce or understand the spoken versions unless you are a good speaker of the language.
Even if you explain yourself properly to the staff and don't end up eating something which has nut put in intentionally, all it takes is for someone to move a utensil from one pot to another to transfer traces (perhaps more than traces) of nut to the food you eat. In a hotel breakfast room another customer could transfer nuts from muesli to something you eat. In some oriental restaurants a garnish of crushed nuts might be added to a nut-free dish by the harassed chef, who may not have been told why you ordered a nut-free dish.
A hot curry can mask the tingling you may get in your mouth if you eat nuts you are allergic to.
If you eat in Chinese restaurants or other oriental restaurants, you are liable to eat nut sooner or later, despite your best intentions and those of the staff. One of my patients was told that saté sauce did not contain peanuts! Peanuts are of course the main ingredient. In fact non-oriental restaurants and hotels are not that safe unless they have very special arrangements in place. For example some fast food restaurants do not sell any products with nuts. Without such a precaution, there is always the possibility of cross-contamination of foods, even if you and the waiter understand each other's language properly.
Even if you tell restaurant staff the problem, they are often extremely busy. Remember, they have their own problems and may not have your rather unusual needs at the forefront of their minds every moment whilst they are handling your food. Remember that "to err is human". Remember that you make mistakes too.
Restaurant staff are increasingly aware of the problem and are in many cases now doing their best, but in most cases we feel that restaurants are inherently unsafe if you have nut allergy.
If you do eat in a restaurant, a good expression to use is:
So don't mince words. State the extreme risk clearly if death is a risk at all, even a tiny risk.
These two of the questions I am asked commonly. The answer is that there seems to be no special link. Allergy to nutmeg does occur, but seems to be rather rare. There has been a suggestion that there may be some cross-reaction with pollens and with celery, but the practical importance of this is not clear. If you are allergic to nuts and have never had a reaction to nutmeg it seems that nutmeg poses no greater risk than a lot of other things you are bound to eat.
Cyril was a happy and healthy little squirrel but, unlike his friends and his sister, he could not munch or touch the ripe nuts which they found amongst the carpet of golden leaves and twisted roots. Find out what happened, and how they all coped.
Beautifully written and illustrated by a young student whose younger sister has nut allergy. A winner.
"Allie the Allergic Elephant"
Nicole Smith's preschool age son was due to enter school and she couldn't find an age-appropriate book to explain his life threatening peanut allergies to his teacher and classmates. So she wrote her own. The book is geared toward ages 2-7, but has received rave reviews from older children too. "Allie" is a wonderful book written about the perils and triumphs of an elephant who tells her life story of what it is like to live with peanut allergies. The book explains allergic reactions (hives, coughing, red eyes) and how to say 'no thank you' to foods offered by other children and adults.
The pictures are enhanced by the fact that a 12 year old did the artwork. She is a very talented artist, and even drew the elephant with hives!
Click on the graphic to vote for this
page as a Starting Point Hot Site
This page contains some important information which we hope you will find useful. We welcome e-mail with questions and tips to help us make the page more useful for people with allergy to nuts.
Interested in a correspondence page? If you are prepared to have your e-mail question and our answer published on these web pages for others to read, mention this. You can see the answer before you agree if you wish. Look at our correspondence page on nut allergy and anaphylaxis
Updates: 28 April 1998 (clearer reference to sesame seed, poppy seed, sunflower seed). 20 June 1998 ( changed and extended text on whether siblings of nut-allergic children should be tested and given adrenaline). 3 September 1998 (Anaphylaxis Campaign website link). 12 & 13 September 1998 (USA airline ban on nuts near allergic patients. Houmous.). 15 Sep 98 (AC & Cyril links improved). 10 Nov 98 (pecan). 30 Dec 98 (product alert). 8 Jan 99 (restaurant safety). 24 Feb 99 a number of text changes following a meeting of specialists to discuss anaphylaxis and nut reactions. 18 Mar 99: curry can mask nut allergy symptoms. 21 April 99: Leanne Rickaby's death. 28 May 99 link corrected. 23 Oct 99 'tasting' foods. Mild reactions in past. 5 & 8 Dec 1999 (Allie book). 28 Jan 2000 link corrected. 27 Jul 2000 out of date material removed. 15 Dec 2000 Nutmeg. 3 Jan 2001 Spanish for peanut, Pakistan, format changes. 23 Jan 2001 peanuts vs other nuts, chestnut, nutmeg. 3 Feb '01 French & German. 4 May 03: Andalucian term for peanut.
Copyright © 1997, 1998, 1999, 2000, 2001, 2003 M. A. Stern