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Good prognosis, clinical features, and circumstances of peanut and tree nut reactions in children treated by a specialist allergy center

https://doi.org/10.1016/j.jaci.2008.05.015Get rights and content

Background

The diagnosis of nut allergy causes anxiety. Few studies exist that estimate risk of reactions and inform management.

Objective

To describe frequency and circumstances of reactions after the institution of a management plan.

Methods

Prospective study of children with peanut/nut allergy with an allergist's management plan. Severity and circumstances of worst reaction before diagnosis (index) and follow-up reactions were evaluated.

Results

A total of 785 children were followed for 3640 patient-years from diagnosis. Index reactions were mild in 66% (516), moderate in 29% (224), and severe in 5% (45). Fourteen percent (114/785) had follow-up reactions (3% annual incidence rate). Ninety percent had the same/reduced severity grade, and 1 of 785 (0.1%) had a severe reaction. Preschool children (n = 263) had a low incidence of reactions, and none were severe. There was a 3-fold reduction in injected epinephrine use from that used in the index reaction, required in 1 severe reaction, never twice; 14% (16/114) required no medication, 78% only oral antihistamines. Forty-eight percent reacted to the index nut type, 19% to a different nut (55% sensitized at diagnosis, 14% not sensitized, 31% not tested). Accidental versus index reactions were 4-fold more likely to be a result of contact exposure rather than ingestion. Contact reactions were always mild. Most (53%) reactions occurred at home, 5% in school, 21% at other sites (21% not recorded). The nut was given by a parent/self in 69 (61%) reactions or teacher in 5 (4%).

Conclusion

With a comprehensive management plan, accidental reactions were uncommon and usually mild, most requiring little treatment; 99.8% self-treated appropriately and 100% effectively.

Section snippets

Methods

Subjects were unselected children with peanut/nut allergy who attended the Allergy Centre in Addenbrooke's Hospital, Cambridge. Eighty percent of subjects had been referred by their primary care physicians. Diagnosis was made after a recent history of a typical type 1 hypersensitivity reaction (urticaria/angioedema ± wheeze ± vomiting ± abdominal pain with change in behavior) occurring within 1 hour of definite nut ingestion together with evidence of sensitization to nuts (usually by skin prick

Subject characteristics

Clinical details of 785 children with peanut and/or nut allergy with median age 68 months (interquartile range, 40-107) were collected over 3640 patient years (mean, 5.3 years; median, 4.0 years); 163 further children who were originally enrolled and characterized had no follow-up. There was no significant difference between median age, sex, nut type causing worst reaction before diagnosis (index reaction), and severity grade of index reaction for groups with or without follow-up. The

Discussion

We have shown a favorable prognosis for children attending a specialist allergy clinic with an annual incidence rate for accidental ingestion of peanut and/or tree nuts after diagnosis of 3%.

This rate is substantially lower than rates in other studies of accidental exposure to peanut alone. For example, in 1989, Bock and Atkins8 found 50% of children with peanut allergy had an accidental ingestion within the past year. Vander Leek et al14 found an annual incidence rate of 33%, and most

References (25)

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Disclosure of potential conflict of interest: A. T. Clark and P. W. Ewan both have received research support from the Food Standards Agency, United Kingdom government.

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