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Peanut allergy

Key sources
The following summarized guidelines for the evaluation and management of peanut allergy are prepared by our editorial team based on guidelines from the European Academy of Allergy and Clinical Immunology (EAACI 2023; 2018; 2014), the American Academy of Family Physicians (AAFP 2023), the Global Allergy and Asthma European Network (GA²LEN 2022), the Wilderness Medical Society (WMS 2022), the American Academy of Allergy, Asthma & Immunology (AAAAI/CSACI/ACAAI 2021), the American Academy of Allergy, Asthma & Immunology (AAAAI/ACAAI 2020; 2014), the American Academy of Allergy, Asthma & Immunology (AAAAI 2020), the British Society for Allergy and Clinical Immunology (BSACI 2017), the National Institute of Allergy and Infectious Diseases (NIAID 2017), and the American Academy of Dermatology (AAD 2014).
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Guidelines

1.Screening and diagnosis

Diagnosis: as per BSACI 2017 guidelines, consider establishing a clinical diagnosis of primary nut allergy based on the combination of a typical clinical presentation and evidence of nut-specific IgE shown by positive skin prick test or specific IgE testing.
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2.Classification and risk stratification

Risk factors: recognize that infants with severe eczema are at the highest risk of developing food allergy, while infants with mild-to-moderate eczema, a family history of atopy in either or both parents, or infants with one known food allergy potentially at some increased risk of developing food allergy (or an additional food allergy).
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3.Diagnostic investigations

History and physical examination
Elicit a detailed medical history and perform a physical examination to aid in the diagnosis of food allergy.
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Consider offering elimination diet and using diet diaries as an adjunctive means to diagnose food allergies but are not to be depended on solely for confirming a diagnosis.
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  • Indications for testing

  • Serum IgE (total)

  • Serum IgE (specific)

  • Skin prick test

  • Intradermal skin test

  • Basophil activation test

  • Food challenge testing

  • Other tests

4.Medical management

General principles: as per AAAAI 2020 guidelines, develop a written anaphylaxis emergency care plan for patients in times of emergency.
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  • Epinephrine autoinjectors

  • Immunotherapy

5.Nonpharmacologic interventions

Peanut avoidance: as per BSACI 2017 guidelines, advise avoidance from peanut as the cornerstone of management as peanut allergy is likely to be a long-lived disease.
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6.Specific circumstances

Patients with food-dependent exercise-induced anaphylaxis
Suspect food-dependent exercise-induced anaphylaxis when ingestion of causal food and temporally related exercise result in symptoms of anaphylaxis. Recognize that symptoms only occur with ingestion of the causal food proximate to exercise and that ingestion of the food in the absence of exercise will not result in anaphylaxis.
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Advise avoiding food ingestion within 2-4 hours of exercise for the prevention of symptoms in patients with food-dependent exercise-induced anaphylaxis, and initiate prompt treatment with the onset of symptoms.
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  • Patients with pollen-food syndrome

  • Patients with food protein-induced enterocolitis syndrome

7.Patient education

General counseling: as per AAAAI 2020 guidelines, advise the following measures for restaurant dining in patients with food allergy:
consider notifying the restaurant in advance of the food allergy
consider involving the manager in the order
consider requesting that the table surface is cleaned with soap and water or commercial wipes
consider providing written instructions about allergy for restaurant staff, such as a "chef card" or "allergy card:
communicate with restaurant staff that trace amounts of allergen can cause a reaction
notify co-diners of food allergy
recognize that certain food establishments more commonly serve nuts, such as Asian restaurants, bakeries, and ice cream shops
recognize that cross-contact is common in buffets where effective cleaning is difficult
recognize that simple dishes with clearly identified ingredients are safer than dishes with mixed ingredients
recognize that allergic ingredients may not always be visible
attempt to keep the dish at the table, if a mistake is made, until a new dish without allergen is delivered
avoid sharing plates with other co-diners
consider dining at off-peak hours.
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8.Preventative measures

Breastfeeding: encourage exclusive breastfeeding for the first 4-6 months of life for the prevention of food allergy.
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  • Early introduction of peanuts

  • Probiotics

9.Follow-up and surveillance

Follow-up
Evaluate pediatric patients with food allergies at regular intervals (1-2 years), according to the patient's age and the food allergen, to determine whether he or she is still allergic. Obtain periodic reevaluation every 2-5 years, depending on the food allergy, if food allergy is unlikely to change over time, as in adults.
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Take into account the natural course of allergies to specific foods when deciding on the frequency of food allergy follow-up evaluations, recognizing that peanut and tree nut allergies do not resolve quickly in childhood. Individualize follow-up (roughly yearly reevaluations in childhood) with less frequent retesting if results remain particularly high (> 20-50 kUA/L).
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10.Quality improvement

School policies: ensure that all staff within the school and early years setting receive appropriate training in managing an allergic reaction.
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  • Restaurant policies