Peanut Allergy

  • Medical Author:
    Syed Shahzad Mustafa, MD

    After growing up in the Rochester area, Dr. Mustafa pursued his undergraduate studies at the Johns Hopkins University in Baltimore and attended medical school at SUNY Buffalo. He then completed his internal medicine training at the University of Colorado and stayed in Denver to complete his fellowship training in allergy and clinical immunology at the University of Colorado, National Jewish Health, and Children's Hospital of Denver.

  • Medical Editor: William C. Shiel Jr., MD, FACP, FACR
    William C. Shiel Jr., MD, FACP, FACR

    William C. Shiel Jr., MD, FACP, FACR

    Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

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Peanut allergy facts

  • The prevalence of peanut allergy in the United States is approximately 1% to 2%.
  • The rate of peanut allergy is higher in individuals with additional allergic conditions or a family history of allergic conditions, including a sibling with peanut allergy.
  • One-third of patients with peanut allergy are also allergic to tree nuts.
  • About 90% of reactions to peanut occur within 20 minutes of exposure.
  • Peanut allergy with asthma is a risk factor for a severe allergic reaction.
  • Peanut allergy symptoms and signs include
  • More severe symptoms and signs include:
  • Epinephrine is the treatment of choice for a systemic allergic reaction to peanut.
  • Roughly 20% of children outgrow peanut allergy by their school-age years.
  • There is no cure for peanut allergy.

What is a peanut allergy?

Peanut allergy develops when the body's immune system has an abnormal, hypersensitivity response to one or more of the peanut proteins. Peanut allergy is one of the most common food allergies in both children and adults. It receives particular attention because it is relatively common, typically lifelong, and can cause severe allergic reactions. Peanut allergy is the leading cause of anaphylaxis and death due to food allergy. It can lead to significant burden on patients and their families. Peanut is a common food ingredient making strict avoidance difficult. Therefore, there is a relatively high rate of accidental peanut ingestions for those trying to avoid peanuts. For all of the above reasons, peanut allergy has become an important public-health issue.

How common is a peanut allergy?

This prevalence of peanut allergy has increased significantly over the past decade, most notably in westernized countries. The prevalence of peanut allergy in westernized countries is approximately 1% to 2%, with the greatest prevalence in children under 3 years of age. This increase in prevalence has also occurred with other allergic conditions, such as eczema (atopic dermatitis), asthma, and hay fever (allergic rhinitis). Peanut allergy is much less common in underdeveloped areas of the world, such as Africa and Asia. Emerging literature suggests that the increasing rate of peanut allergy may be leveling off in many nations, including the United States.

Why is peanut allergy increasing and what are risk factors for a peanut allergy?

It is not clear why the rate of peanut allergy is increasing in the United States and other westernized nations. This is an area of active medical research. Risk factors for peanut allergy include a personal or family history of allergic conditions, such as asthma, hay fever (allergic rhinitis), and particularly eczema (atopic dermatitis). A sibling of a child with peanut allergy has approximately a 7% chance of developing peanut allergy, as compared to the baseline population risk of 1% to 2%. Other factors influencing peanut allergy include exposure during pregnancy and lactation, exposure to peanut protein through household dust, and exposure to skin-care products containing crude peanut oil.

There has been significant recent research on the timing of peanut exposure into a child's diet and its effect on the risk of allergy. In the early 2000s, recommendations were to delay the introduction of peanuts until 3 years of age. The rates of peanut allergy more than doubled in countries following these recommendations. It was also observed that rates of peanut allergy were significantly lower in countries, such as Israel, where children were introduced to peanuts at a younger age. In 2008, the recommendation regarding delayed introduction of peanut was retracted, and research began to indicate that earlier introduction of peanut may be protective against food allergy. In a landmark study publish in 2015 (LEAP study), it was shown that early introduction of peanut into a child's diet, at 4 months of age, significantly decreased the risk of developing peanut allergy in a high-risk population. This study, along with additional research, may very well lead to updated guidelines on the timing of introduction of peanuts and other highly allergenic foods into a child's diet.

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Food Allergy Triggers

It's common to have a bad reaction to foods we eat on occasion, such as gas from eating beans or headaches from drinking wine. If you're lactose intolerant you may experience diarrhea when you consume dairy. These are all examples of food sensitivities or intolerances, which are different from allergies in that they are not immune system reactions. With a food allergy. The immune system reacts to specific foods which can result in symptoms that range from:

  • mild skin rashes or
  • itching,
  • to anaphylaxis, a serious reaction that can be fatal.

What are peanut allergy symptoms and signs? How do physicians diagnose a peanut allergy?

The most important step in the diagnosis of peanut allergy is a detailed history. A good history may essentially make the diagnosis of a peanut allergy. Important factors for a suggestive history of peanut allergy include the following:

Timing of symptoms: The majority of reactions occur within 20 minutes, with nearly all reactions occurring within two hours of exposure to peanuts.

Types of peanut allergy symptoms: About 80% to 90% of reactions involve skin manifestations such as

Nevertheless, reactions can occur in the absence of a rash, and these reactions may be the most severe. Other common signs and symptoms involve the

Consistency: Reactions should consistently occur with every peanut exposure.

Following the history, the skin prick test (SPT) is generally the test of choice in making a diagnosis of peanut allergy. It is very important to be aware that a positive SPT alone does not make the diagnosis of peanut allergy. Of note, many individuals with a positive SPT to peanut will not be peanut allergic. The usefulness of a peanut SPT increases as the size of the reaction increases. Sometimes, SPT results are inconclusive and may be followed up with a blood test known as peanut specific IgE levels.

Similar to the SPT, peanut-specific IgE levels must be interpreted based upon the clinical history. Undetectable peanut-specific IgE levels do not rule out the possibility of peanut allergy, with reaction rates of up to 20% being reported in individuals with undetectable peanut-specific IgE. Much like SPT, the likelihood of true peanut allergy increases with increasing levels of peanut-specific IgE.

Despite a thorough clinical history, SPT, and peanut-specific IgE levels, the diagnosis of peanut allergy may still remain in question. In these instances, a physician-supervised oral food challenge (OFC) may be indicated. In an OFC, patients are given gradually increasing amounts of peanut, usually in an allergist's office, and closely monitored for allergic symptoms. OFCs have not only been shown to significantly improve quality of life regardless of whether the challenge is passed or failed, but they have also been shown to be very safe when performed in an appropriate setting under the supervision of a physician experienced in the management of food allergy. During the diagnostic process of peanut allergy, it is also important to determine if peanut-allergic individuals are allergic to tree nuts, since up to one-third of patients with peanut allergy will also react to tree nuts.

How are peanut allergies managed? What is the treatment for a peanut allergy?

Strict avoidance of peanuts and prompt treatment of accidental ingestions are the mainstays of management of peanut allergy. The goals of treatment are to minimize the risk of accidental ingestion while maintaining adequate nutrition and an acceptable quality of life. Although there is significant research focused on oral immunotherapy and desensitization protocols for peanut allergy, these treatment options are still not ready for widespread clinical use. There is also significant research involving a peanut patch, also known as epi-cutaneous immunotherapy. Early studies of this patch have shown that by applying a patch containing peanut protein to the skin, it may be possible to make peanut allergic individuals less sensitive to peanut protein and it may protect certain peanut-allergic individuals from experiencing a reaction to an accidental peanut exposure. There are still many questions regarding this possible form of therapy and it is still not ready for widespread clinical use.

Peanut is a common food in the Unites States, and strict avoidance requires constant awareness of food labels and food ingredients. United States legislation requires all food companies to identify on labels whether their products contain the most common food allergens, including peanuts. Advisory labeling practices, such as those stating "may contain peanut," "manufactured on shared equipment with peanut," or "manufactured in the same facility as peanut," are not regulated. The potential risk of ingesting peanut from foods labeled with advisory labeling is unknown, so peanut-allergic individuals should also avoid these foods.

Despite attempts at strict avoidance, accidental ingestions occur in up to 15% of patients per year. All individuals with a peanut allergy should have an emergency action plan outlining the treatment plan for an acute reaction. Since epinephrine injection is the only treatment for a significant allergic reaction, all individuals with a peanut allergy should carry an epinephrine auto-injector (Auvi-Q, Epipen, Twinject) at all times. Although antihistamines such as diphenhydramine (Benadryl) may also be used in the management of acute allergic reactions, epinephrine generally remains the treatment of choice. Individuals who experience an acute allergic reaction to an accidental peanut exposure should also notify a health-care professional. It is very important to note that the severity of acute reactions is variable and cannot be predicted by diagnostic testing or previous reactions. Risk factors for poor outcomes from peanut allergy include asthma and delayed treatment with epinephrine.

There are important additional considerations in managing and counseling individuals with peanut allergy. Research has shown that reactions due to skin contact are typically limited to the site of contact and unlikely to cause a systemic reaction or anaphylaxis. Similarly, the vast majority of peanut-allergic individuals will tolerate being around peanuts and the smell of peanut, since peanut protein is not airborne. The majority of peanut-allergic individuals will also tolerate peanut oil, since the peanut protein is not present in the highly purified oils, except in the rarer cold-pressed oils. Although peanut is a legume, most peanut-allergic individuals will also tolerate other legumes, such as soy, peas, and green beans. Exposure to peanut through another person's saliva (such as from kissing) has been shown to trigger a reaction. All peanut-allergic individuals should discuss these considerations and other questions with their health-care provider.

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Can a peanut allergy be cured or outgrown?

Unfortunately, there is no cure for peanut allergy. Although the natural history of peanut allergy is often difficult to predict, peanut allergy can be outgrown. Approximately 20% of children with peanut allergy will tolerate peanuts by their school-age years. Favorable factors to outgrow peanut allergy include smaller SPT at the time of diagnosis, lower specific IgE levels at the time of diagnosis, milder initial reaction to peanuts, and minimal additional allergic conditions, including a lack of additional food allergies (particularly tree nuts). If there is a significant likelihood that a child has outgrown peanut allergy, a physician-supervised oral food challenge can be pursued.

REFERENCE:

Du Toit, George. "Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy." New England Journal of Medicine 372 (2015): 803-813.

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Reviewed on 11/3/2015
References
REFERENCE:

Du Toit, George. "Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy." New England Journal of Medicine 372 (2015): 803-813.

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