Tree Nuts Anaphylaxis in Preschool Age Children

Abstract

Introduction: The incidence of food-induced anaphylaxis (FIA) is increasing in young children. Although the commonest culprits are cow's milk and egg, FIA to tree nuts (TNs) have been increasing. Objective: Characterization of children referred to our allergy department due to TNs-induced anaphylaxis (TNs-FIA) during preschool age. Materials and Methods: We have retrospectively included 25 children with clinical history of preschool TNs-FIA, proven by allergological work-up. TNs sensitization was assessed by skin prick tests and/or specific IgE. Results: The mean age of the first anaphylactic episode was 3.1±1.2 years. The majority (92%) had an allergic disease (52% asthma). The implicated TNs were cashew (11 children), walnut (8), pine nut (5), hazelnut (2) and almond (1). The reaction occurred after the first known ingestion in 68%. In 92%, symptoms appeared within 30 minutes after exposure. The most frequent clinical symptoms were mucocutaneous (96%), respiratory (80%) and gastrointestinal (52%). Twenty-one children were admitted to the emergency department, although only 48% were treated with epinephrine. An underneath IgE-mediated mechanism was proven in all cases. Immunologic cross-reactivity with other TNs was identified in 84%, and with peanut in 36%. Overall, in our center, TNs-FIA represents 18% of all causes of FIA. Conclusions: In preschool age children with TNs-FIA, cashew and walnut were the commonest implicated nuts. Most reactions occurred briefly after exposure to minimal amounts of TNs, demonstrating the high potency of these allergens. About one-third also had peanut sensitization. Potentially life-threatening TNs allergy can occur early in childhood and adequate management should be undertaken.

Anaphylaxis in children and adolescents: The Portuguese Anaphylaxis Registry

“…These results diverge from other European studies, where hazelnut was the most common TN 8,15 . In a recent Portuguese case series in children at pre‐school age, cashew and walnut were also the most common TNs 17 . FIA has important repercussions in quality of life, as contact with food allergens, even in trace amounts, as hidden or cross‐reacting allergens, may be life‐threatening.…”

Anaphylaxis: A Decade of a Nationwide Allergy Society Registry

“…TNs-induced anaphylaxis has been increasingly reportedworldwide, in particular in preschoolers [14,23,24,26].In this case-series, TNswere an importantcause of FIA,being the second cause inchildren; walnut and cashewwere the most commonreportedTNs. These results diverge from other European studies,where hazelnut was the most frequent TN [8,24].In a case-series reported from a single center in our country, in Coimbra, TNs were the main cause of FIA in adults, especially walnut and hazelnut [27].By contrast, in arecent study also conducted in our country, involving preschoolers, cashew and walnut were the commonestTNs [26]. LTPsare a common cause of FIA in the Mediterranean area [9,[28][29][30],and have been pointed out as the main elicitor of FDEIA [28,30,31].Food management in these patients is challenging [30][31][32],due to the presence of these panallergens in a great number of plant foods,like fresh fruits, vegetables, TNs and seeds.In studies conducted in Italy [28] and Spain [32], LTPs are reported as the main cause of FIA in adults, especially peach.…”

“…Labeling and education of patients and caregivers areessential for allergen avoidance [4,23]. TNs-induced anaphylaxis has been increasingly reportedworldwide, in particular in preschoolers [14,23,24,26].In this case-series, TNswere an importantcause of FIA,being the second cause inchildren; walnut and cashewwere the most commonreportedTNs. These results diverge from other European studies,where hazelnut was the most frequent TN [8,24].In a case-series reported from a single center in our country, in Coimbra, TNs were the main cause of FIA in adults, especially walnut and hazelnut [27].By contrast, in arecent study also conducted in our country, involving preschoolers, cashew and walnut were the commonestTNs [26].…”

“…Food allergywas the main elicitor of anaphylaxis, as it has been described in several case-series, especially when children are included [8,11,13,15,16,[20][21][22][23].Shellfish and CM were the main culprits, in adults and in children, respectively. CM was the leading cause in children, as reported by others [6,15,16,18,21],especially in the first years of life [6,15].These findingsdiverge from those of other authors [8,14,[23][24][25],underlining the importance of having a detailed knowledge of each country's reality.The observed frequency has variations, based on the studied age group, the geographical region and the associated food habits [6,13,14,24,26].Other main foods in this study were fresh fruits and TNs. FIAhas important quality of life repercussions, as contact with food allergens, even in minimal amounts, ashidden allergens or cross-reacting allergens, may be life-threatening.…”

Is the clinical manifestation of anaphylaxis in children influenced by the trigger of reaction?

“…Both age distribution and type of allergens (triggers) were comparable with the Anaphylaxis Registry showing that food such as cow’s milk and hen’s egg caused 88% of reactions in children younger than 6 years, as well as other studies in the youngest children with anaphylaxis history [ 17 – 19 ]. An increasing number of paediatric reports indicated a growing role and strong allergic potential of the nuts, in particular tree nuts in the preschool children who developed allergic reactions to cashews and walnuts independent from their peanut or legumes allergy [ 20 – 22 ]. In our material, the tree nuts such as hazelnuts, walnuts, and cashews ( n = 6) caused an anaphylactic reaction in children aged 0–10 years twice more often than peanuts.…”