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Peanut Allergy and Tree Nut Allergy – The Facts
The peanut is a legume, related botanically to foods such as peas, beans and lentils.
Tree nuts are in a different botanical category and include almonds, hazelnuts, walnuts, cashew nuts, pecans, Brazil nuts, pistachios and macadamia nuts.
As the botanical category is different, many people only react to peanut and not tree nuts, and vice versa.
A key message for people with peanut or tree nut allergy is take your allergy seriously.
You should visit your GP and ask to be referred to an NHS allergy clinic for a proper assessment and high-quality advice.
How common are peanut and tree nut allergies?
Nut allergies are common and affect approximately 1 in 50 children and around 1 in 200 adults in the UK.
What are the symptoms of a nut allergy?
The symptoms of a food allergy can come on rapidly, within minutes of eating the food. These may include nettle rash (otherwise known as hives or urticaria) anywhere on the body or a tingling or itchy feeling in the mouth.
The term for this more serious form of allergy is anaphylaxis. In extreme cases, there could be a dramatic fall in blood pressure (anaphylactic shock).
The person may become weak and floppy and may have a sense of something terrible is happening. This may lead to collapse and unconsciousness.
Most healthcare professionals consider an allergic reaction to be anaphylaxis when it involves difficulty in breathing or affects the heart rhythm or blood pressure.
More serious symptoms of a peanut allergy or tree nut allergy may include:
Swelling in the throat and/or mouth
Difficulty breathing
Severe asthma
Colicky abdominal (stomach) pain
Feeling faint, dizzy, or very sleepy
How can I get a diagnosis?
If you suspect or know you have a peanut or tree nut allergy you need to go to your GP and seek a referral to an NHS allergy clinic for a thorough assessment. This will include tests to confirm which types of nuts are responsible for causing your symptoms.
A referral is important even if your symptoms were mild because it is possible that a future allergic reaction could be more severe.
According to experts, you are at high risk if:
You have had a severe reaction in the past, such as swelling in the throat, breathing difficulties (even mild) or faintness
You have asthma as well as an allergy, particularly if that asthma requires regular use of preventer inhalers
You have had an allergic reaction to a tiny amount of peanut or tree nut
How is an allergic reaction treated?
If peanut allergy or tree nut allergy is confirmed, you may be prescribed adrenaline auto-injectors (AAIs) for use in an emergency. The UK’s Medicines and Healthcare Products Regulatory Agency (MHRA) and the National Institute for Health and Care Excellence (NICE) recommend that medical professionals prescribe two AAIs, which patients should carry at all times in case one is broken or misfires or a second injection is needed before emergency help arrives.
After an adrenaline injection has been given, someone must dial 999 immediately, as symptoms may return after a short period and more than one injection may be required. The emergency service operator must be told the person is suffering from anaphylaxis (pronounced ana-fill-axis).
The adrenaline auto-injectors available in the UK are EpiPen, Jext and Emerade. If you are prescribed AAIs, you will need to know how to use them and regular training in their use is essential. Correct usage of an injector will significantly reduce the risk of an allergic reaction progressing. Ask your GP or allergist for advice.
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What are the risks and how can they be managed?
A recent review of fatal food anaphylaxis data in the UK found that peanut and tree nut allergies are the most common known food triggers, however, the proportion of deaths due to peanut and tree nut allergies from 1998 to 2018 has decreased in the UK.
The age of the person with the allergy could be a risk factor. One study found fatal reactions to food are more likely to occur between the ages of 17-27. As young people begin to manage their allergies for themselves, they may be less cautious with regard to risk, reluctant to ask direct questions in restaurants and subject to peer pressure.
Once you have a confirmed peanut or tree nut allergy diagnosis, it is important to exclude your allergen from your diet. Read food labels carefully and question staff in restaurants, takeaways and other catering establishments.
Top food tips for managing nut allergy
Watch out for satay sauce (made with peanuts), pesto sauce (which can contain tree nuts such as cashew nuts) and marzipan and praline (confectionery products made with nuts). Salad dressings may contain nut oils.
Curries and other Asian dishes are high risk because many of them contain peanuts or tree nuts and their presence may not be obvious if the food is spicy.
Studies focusing on takeaway meals have shown that even when nut-free meals were ordered, a significant proportion still contained nuts.
Foods likely to contain peanuts or tree nuts include the following: cakes, biscuits, pastries, cereal bars, confectionery, ice cream, desserts, vegetarian products, salads and salad dressings.
Watch out for peanut shoots as they are being sold in some UK shops. They can be used in stir-fry dishes and salads and could be mistaken for bean sprouts.
Roasting and heat treatment do not reduce the allergenicity (capacity to produce an allergic reaction) of peanuts or tree nuts. In fact, laboratory experiments have suggested that roasting and heating peanuts (but not boiling) may increase their allergenicity.
Which other foods should I avoid?
Some people with a peanut allergy may be allergic to tree nuts, and some people allergic to one tree nut may be allergic to others.
Research suggests a significant number of people with a cashew nut allergy are also allergic to pistachios.
There is a similar link between walnut and pecan nuts.
There is also the possibility of certain nuts coming into contact with others during food production.
Eating nuts from the shells helps reduce the risk of cross-contamination from other nuts.
If you have an allergy to peanuts or to one type of tree nut, it is important to have allergy testing for other nuts so your allergy specialist can advise on including them in your diet. Research suggests it is important to include nuts you are not allergic to in your diet, as this helps to maintain tolerance and avoid developing an allergy to those nuts in the future. Introduction of other nuts must only be done as advised by your allergy specialist, after allergy testing.
Legumes: Peanuts are actually legumes. A small number of people with a peanut allergy may react to other legumes (such as soya, peas, chickpeas, fenugreek, beans and lentils). One research study found 5% of children with a legume allergy reacted to more than one legume.
Lupin: Lupin is a legume. Studies have shown that some people with a peanut allergy react to lupin.
Sesame seeds: A US study found children with a history of reactions to both peanuts and tree nuts were more likely to have allergic reactions to sesame. A recent European study also found a link between peanut, tree nut and sesame seed allergies.
Other foods: People with nut allergies frequently ask if they should avoid certain foods with “nut” in the name – even those that are botanically different to tree nuts. These include pine nuts, coconut, nutmeg and chestnut. If you are allergic to nuts and have never had a reaction to any of these foods, it is likely that they are safe for you to eat.
Your allergy specialist will be able to give you specific advice regarding which foods you should avoid.