What to do if a 6-month-old infant experiences an allergic reaction to nuts?

Management of Allergic Reaction to Nuts in a 6-Month-Old Infant

If a 6-month-old infant is experiencing an allergic reaction to nuts right now, immediately administer intramuscular epinephrine and call 911, as epinephrine is the first-line emergency treatment for anaphylaxis in pediatric patients. 1, 2

Immediate Recognition and Action

Recognize Allergic Reaction Symptoms

Mild symptoms include: 3

• New rash appearing after nut exposure
• Few hives around the mouth or face

Severe symptoms requiring immediate epinephrine include: 3, 4

• Difficulty breathing, wheezing, throat tightness, or repetitive coughing
• Vomiting or diarrhea
• Swelling of lips, tongue, or face (angioedema)
• Collapse, faintness, or loss of consciousness
• Any combination of symptoms involving multiple organ systems

Emergency Treatment Protocol

Administer intramuscular epinephrine immediately for any concerning symptoms—this is the only appropriate first-line treatment. 1, 2, 4

• Intramuscular route is superior to subcutaneous for children of all weights 2
• Clinical use data support weight-based dosing for pediatric anaphylaxis treatment 1
• Do not delay epinephrine while administering adjunct medications like antihistamines or corticosteroids 2, 4

Call 911 immediately after epinephrine administration or if you have any concerns about the infant's response. 3

Post-Reaction Monitoring

Observation Period

Monitor the infant for 4-12 hours for potential biphasic reactions (recurrence without re-exposure). 2, 4

• Children with resolving symptoms, no history of asthma, and no previous biphasic reactions may be observed for as few as 3-4 hours before emergency department discharge 2
• Biphasic reactions are rare but can occur, requiring extended observation 2, 4
• Admission is reserved for patients with unimproved or worsening symptoms 2

Follow-Up Management

Allergy Evaluation and Testing

Refer to a pediatric allergist for comprehensive evaluation, specific IgE testing, and development of an emergency action plan. 5, 4

• Peanut-specific IgE or skin prick testing should be performed to confirm the allergy 5
• Testing for tree nuts should also be considered, as 34% of peanut-allergic children also react to tree nuts 6
• Patients may have IgE antibodies to nuts they've never knowingly been exposed to (50-82% for various tree nuts) 6

Prescription and Education

All infants with confirmed nut allergy must be prescribed an epinephrine auto-injector with comprehensive caregiver training. 2, 4, 7

• Training should include demonstration with a training device and written instructions 7
• Caregivers should understand specific symptoms requiring injection: breathing difficulties, angioedema, collapse/faintness, or anaphylactic shock 7
• Multiple auto-injectors should be available at home, school/daycare, and carried during outings 7

Avoidance Strategy

Implement strict avoidance of all peanuts and tree nuts, with education about cross-contamination risks. 6, 4

• Accidental ingestions occur in 55% of peanut-allergic children over time, averaging two accidents per patient 6
• Common modes of accidental exposure include: shared food, hidden ingredients, cross-contamination, and craft projects using peanut butter 6
• Accidents occur frequently at school, home, and restaurants 6

Important Clinical Caveats

Never give whole nuts to children under 4 years of age due to choking risk, even if allergy testing is negative. 5

Nut allergies are rarely outgrown and are potentially life-threatening. 6, 8

• Peanut and tree nut allergies persist in most children, unlike milk and egg allergies which often remit 8
• Initial reactions can occur on first known exposure in 72% of cases 6
• Reactions can be severe even on first exposure, with 38 of 190 first reactions requiring epinephrine treatment 6

Risk factors for severe or fatal reactions include: 4

• Coexisting asthma
• Peanut and tree nut allergy specifically
• Delayed epinephrine administration