What is the management approach for a confirmed nut allergy?

Management Approach for Confirmed Nut Allergy

The management of confirmed nut allergy requires strict avoidance of the culprit nut(s), carrying emergency medication including epinephrine auto-injectors, and education on recognizing and treating allergic reactions. 1, 2

Immediate Management Essentials

Emergency Medication

• Epinephrine auto-injector prescription and training:
  • Adults and children ≥30 kg: 0.3-0.5 mg (0.3-0.5 mL) intramuscularly in anterolateral thigh
  • Children <30 kg: 0.01 mg/kg (0.01 mL/kg) intramuscularly, maximum 0.3 mg per injection
  • Repeat every 5-10 minutes as necessary based on clinical response 3

Avoidance Strategy

• Complete avoidance of confirmed allergenic nuts:
  • Read all food labels carefully for nut ingredients
  • Be aware of potential cross-contamination in restaurants, bakeries, and manufactured foods
  • Avoid foods with precautionary allergen labeling (e.g., "may contain nuts") 4, 5

Patient/Family Education

• Train on proper use of epinephrine auto-injector
• Recognize early symptoms of allergic reactions:
  • Mild symptoms: new rash, hives around mouth or face
  • Severe symptoms: widespread hives, difficulty breathing, coughing/wheezing, swelling of tongue/lips, pale/blue skin 1
• Implement emergency action plan when symptoms occur

Selective vs. Complete Avoidance

Selective Avoidance Approach

• Recent evidence suggests that many patients with specific nut allergies can safely consume other nuts 5
• Consider referral to allergist for:
  • Component-resolved diagnostic testing to identify specific nut allergens
  • Supervised oral food challenges to determine which nuts can be safely consumed 6, 5

Complete Avoidance Approach

• Safest initial approach, especially for:
  • Young children
  • Patients with history of severe reactions
  • Multiple nut allergies
  • Limited access to specialized allergy care 4, 7

Long-term Management

Regular Follow-up

• Annual reassessment of:
  • Emergency medication needs
  • Accidental exposure events
  • Quality of life impact
  • Potential for outgrowing the allergy (approximately 10% resolution rate) 4

Emerging Treatment Options

• Oral immunotherapy (OIT):
  • Most studied approach for desensitization
  • May provide protection from accidental exposures
  • Should be performed only under specialist supervision 2
• Omalizumab:
  • Only approved alternative management for reducing reactions from accidental exposure
  • May be used as monotherapy or to facilitate OIT 2

Special Considerations

Children

• Developmental considerations:
  • Whole nuts should not be given to children under 5 years due to choking risk
  • Peanut butter directly from spoon or in lumps should not be given to children under 4 years 1
• School management:
  • Provide written emergency action plan
  • Ensure school staff training on epinephrine administration
  • Consider allergen-free zones in cafeterias

Cross-reactivity

• Clinical cross-reactivity between different nuts varies
• Positive tests to multiple nuts may reflect cross-sensitization rather than true clinical allergy
• Component-resolved diagnostic testing can help differentiate between primary allergy and cross-sensitization 6, 5

Common Pitfalls to Avoid

• Delayed epinephrine administration: Always use epinephrine as first-line treatment for anaphylaxis
• Relying solely on antihistamines: These medications cannot treat severe reactions
• Incomplete label reading: Ingredients can change; always check every time
• Assuming cross-reactivity: Don't unnecessarily restrict diet without confirmed allergies
• Neglecting to replace expired auto-injectors: Check expiration dates regularly