Frequently Asked Questions (FAQ's)

How dangerous is nut allergy?
It may surprise you that we think the risk that a pre-teenage child with nut allergy will have a fatal reaction is so small that the wisdom of supplying adrenaline syringes for them is highly questionable. For the whole of the USA we are currently aware of only three such deaths over many years, far fewer than from a huge variety of other causes. Both in Britain and in the USA children's specialists working on nut allergy are trying hard to establish the facts, and it seems likely that when we are more certain about the facts we will be able to be much more reassuring about nut allergy in the youngest age groups. Of course the simple fact is that anyone who is alive has a risk of dying. If it turns out that the risk from nut allergy is much smaller than the risk from a number of other everyday things, our efforts would be much more sensibly devoted to those other risks. No drug is entirely harmless, and adrenaline (epinephrine) injections carry slight risks of their own. If the risk from nuts is low enough, it will be outweighed by the risks of giving adrenaline.
Of the small number of deaths due to nut allergy which happen each year (a handful or thereabouts in the UK each year), most seem to happen in teenagers and people in their twenties, perhaps because they take more risks, but also for reasons we don't understand. Certainly the risk in these age groups is a lot higher than in pre-teens. Even so, deaths from accidents are far more common than deaths from nut allergy in this age range.
Beyond the teens the risk of having a reaction in any one year seems to go down for most people, but if you have a serious anaphylactic reaction the risk of dying from it seems to increase with age. This is probably because the heart and blood vessels can't cope with such a reaction nearly so well as in the young.
But for all age groups nuts are a very minor overall risk to life compared to other everyday risks. The balance of opinion is that the risk from nuts is one we can do something about and that we should therefore do so.
Though we have a probably fairly good idea about the risk of death from nut allergy in the whole population, at the moment we don't know enough to be precise about the size of the small risk in someone who is already known to be allergic to nuts. The reason is that we are not sure enough yet about how many people have nut allergy, so we can't work out the fraction who have fatal reactions.

Are there any cures for nut allergy?
Desensitising injections have been tested but are not generally recommended; they are still regarded as experimental. Scientists have come up with a number of other ideas which may enable us to make people with nut allergy safe. At least one of these is being tested now, but it is not available for prescription.

What is the most dangerous time of life for nut allergy?
Small children are amazingly good about avoiding nuts if they are allergic to them. Parents make few mistakes. The main danger to children seems to come from mistakes made by adults other than their parents. That said, some foods contain nuts in a way which is not obvious, and anyone will make a mistake occasionally. Before the teenage years children also seem to have a much smaller risk of dying than teenagers and adults even if they do have anaphylaxis. For example this is true of young children who have anaphylaxis from bee or wasp stings, when they are stung with the same amount of venom as an older person.
The biggest risk period seems to be in the teens and young adulthood, perhaps because young people of this age become more independent, are no longer protected by parents so much of the time, and may not be so strict about keeping their treatment with them all the time.
Beyond the teens and twenties the impression is that the risk of accidentally eating nuts becomes smaller again as we adopt a less risky and variable lifestyle. But older people who do get anaphylaxis are more likely to die of it. One reason for this is probably that heart disease and hardening of the arteries make us more vulnerable as we get older.
Age is not the only thing which has a big effect on the risk. For example if you have asthma your riks is greater, because if you get anaphylaxis the asthma is prone to become very bad as part of this. People with asthma who get anaphylaxis need to be particularly careful to use preventive drugs for their asthma to cut this risk.

One of my children has nut allergy. Should I have my other children tested for nut allergy?
This is a difficult problem right now. We feel that such testing is NOT appropriate. The reason is that tests would undoubtedly be positive in many children who can safely eat nuts, a so-called 'false positive' test result. Many children would end up carrying emergency treatment unnecessarily, and in the nature of things some will end up getting the treatment inappropriately. This is not just a problem with allergy, but with many medical tests; a test which is quite good for diagnosing a condition in someone with symptoms suggesting that condition becomes a very poor test when applied to large numbers of people who have never had the symptoms.
But...
Allergy runs in families, and nut allergy affects people with allergies in the family. Nut allergy is now quite common as medical conditions go. We have certainly had positive results on brothers or sisters when we have tested them. Perhaps this is important. We will only really know when we have found out more about whether such brothers or sisters really have reactions in practice often enough for this to demand action. At the moment we in our clinic believe it is wrong to prescribe adrenaline kits for children who have never had a reaction to nuts.
A fallacy
A fallacious argument goes as follows. "My child has a brother or sister with nut allergy and has a positive skin test. Because nut allergy may run in families to some extent there may be a reaction to nuts, and I cannot be absolutely sure that the first reaction will not be fatal. Therefore my child should have an adrenaline kit." This sounds logical, but is not.
Firstly, without question giving adrenaline kits on this basis could double the number of children carrying adrenaline. But the additional kits would be given to children with a much lower risk than those given adrenaline at present. It is highly possible (in my estimate virtually certain) that this would result in more harm than good (in my view much more harm than good). Inevitably some of the kits end up being used inappropriately. The practical and psychological burden from an adrenaline kit is far from negligible for the family, for the school, and for other carers.
Secondly, skin tests (or blood tests) are far from absolutely reliable. A positive result by no means guarantees that the child will react when it eats nuts. In children with negative test results we also cannot be absolutely sure there will not be a reaction and that the first reaction will not be fatal. In fact we can't be absolutely sure of anything in this area, and logically we would soon be in the ludicrous position of giving an adrenaline kit to every child in the world.
The flaw in the argument lies in the word absolutely.
In truth we cannot be absolutely sure of anything where health is concerned, and trying to achieve such certainty is pointless and even dangerous. You and I cannot be absolutely sure we won't be struck dead by lightning tomorrow, be diagnosed as having leukaemia next week or even succumb to nut allergy the next time we eat nuts ourselves even if we have not been allergic to them before. But no sensible person goes around wearing a lightning conductor or taking routine action against the other possibilities. We live with mostly larger risks, such as those of being killed in a road accident.
Risk is always present in life. Being alive means living with risk. The sensible question is whether a health risk and the benefit of treatment are large enough to justify the inconvenience, risk and expense of treatment. It is not at all a matter of absolute principles, but of the size of the risk and then the size of the beneficial and harmful effects of the treatment.
We do not have even remotely accurate ideas about the size of these risks and benefits in children who have never reacted. The inaccurate ideas we do have suggest that adrenaline is NOT appropriate for brothers or sisters of nut-allergic children. Future research could fill in our knowledge. Right now we must act on the knowledge we have now. The risk that a first reaction will be fatal is not non-existent, but it is generally agreed to be extremely small, and smaller than many other risks in life.
It is a sound principle to use medical treatments only where there is positive evidence that they are appropriate. This is not the case with the issuing of adrenaline kits for children who have never had a reaction, whatever may have happened to their brothers or sisters.

If you've only had mild reactions, does this mean future reactions will be mild as well?
Although this seems to be true for most people, there are exceptions. The vast majority of reactions to nuts don't kill in any case. But the stories of people who died from nut allergy show that this can happen even to someone who has only had mild reactions before. So to be on the safe side we often regard nut allergy as dangerous even if none of the previous reactions have been dangerous.

Is peanut oil dangerous?
Amazingly, people who are allergic to peanuts only rarely have reactions to peanut oil which has been refined. It seems you don't need to go around in constant fear that, unbeknown to you, some food may have been prepared with refined peanut oil. Whether it is a good idea to consume foods made with it is another matter. One reservation is that much peanut oil is produced in countries which do not have the same strict regulations and working conditions as those in Western Europe or North America. It is thus impossible to be perfectly sure, for example, that unrefined peanut has not been added with the idea of improving the flavour. With increasing awareness of peanut allergy, this problem, which seems to have been small at worst, will surely decrease.
Unrefined or 'cold pressed' peanut oil, or 'gourmet oil' with peanut material added for flavour are dangerous.
'Vegetable oil', according to our information, will not intentionally contain peanut oil because peanut oil is considerably more expensive. Some is produced with machinery also used for peanut oil and may thus be contaminated with it. This seems unlikely to be important.
Although refined oil does not seem to cause reactions, it seems conceivable that ultra-minute traces of peanut protein in it, insufficient to cause symptoms, might still sensitise someone, or worsen the sensitivity. This is just a theoretical possibility, and there is no proof that it happens. A very poor piece of evidence is the widely expressed view that peanut oil in nipple creams made for breastfeeding mothers may be the reason for the increase in nut allergy. However, if that view were right, it would exactly show that oil which did not cause symptoms did sensitise.
RECENT EVIDENCE:
British Medical Journal 12 April 1997.
Good news from the research team in Southampton, at the University Department of Child Health. This team has done more research on nut allergy than any other group in Britain. They have now tested peanut oil on people with peanut allergy more thoroughly than anyone else. They gave 62 adults with peanut allergy refined peanut oil, up to 10 ml. None of the volunteers had allergic reactions to refined peanut oil.
But crude unrefined peanut oil did cause reactions in 6 out of the 62 peanut allergic volunteers. These reactions were not severe, but clearly people with nut allergy must avoid such oils. The team write that products should be labelled so that crude unrefined oil, which is potentially dangerous, can be distinguished from refined oil, which seems to be safe. Who could argue with that? Some 'gourmet oils' have had peanut material added to provide a peanut flavour; these are obviously like unrefined oil.
COMMENT:
Although the refined oils did not cause dangerous reactions, this may not quite be the whole story. Theoretically it is possible that traces of peanut protein which cannot cause a reaction would nevertheless sensitise someone, or increase the sensitivity of someone who is already allergic. To find out if this happens, a quite separate research project would be needed, but this might not be possible. We recommend that if you are allergic to peanuts you should avoid any peanut oil if possible, but not get too worried if you make a mistake about refined peanut oil. The advice is an attempt to play safe, just in case undetectable traces of protein in refined oil can increase allergy. We emphasise, this is a theoretical point with no practical evidence to support it. All the evidence is that refined peanut oil does not cause dangerous reactions.

What are the side effects of adrenaline (epinephrine)?
In the doses we recommend, trembling, palpitations (feeling your heart beating fast), and a feeling of tension or anxiousness are quite likely to happen, though many people donÕt notice any of these things. These are normal effects of the adrenaline and soon wear off. Higher doses cause an extremely unpleasant feeling and may be dangerous to the heart.
If you have some other medical conditions such as high blood pressure, or an abnormal heart rhythm, or narrowing of the coronary arteries, or if you are treated with some other medicines such as medicines for depression, special caution is needed with adrenaline, and a specialist should advise you.

If my child is allergic to one kind of nut, are other kinds of nut dangerous too? Are people with peanut allergy likely to be allergic to tree nuts (and vice versa)?
Quite often they are not, but unfortunately many children and adults who are allergic to one kind of nut also become allergic to other kinds. This includes not only peanuts, almonds, brazil nuts, cashew nuts, hazel nuts, pistacio nuts, walnuts and pecan nuts, but also in rather fewer people coconut, sesame seed, poppy seed, sunflower seed, and pine kernels.
It is surprising that allergy to peanuts does go together with allergy to tree nuts, because peanuts are closely related to peas and beans and not closely at all to tree nuts. Nevertheless allergies seem to ignore the botanists and their classifications in this. We don't know why. If you are allergic to peanuts you're far from certain to be allergic to the other nuts, but the risk of that is far higher than in people who don't have peanut allergy. The same is true the other way round. If you are allergic to tree nuts, you are more likely to become allergic to peanuts. Skin and blood tests often show allergy to more kinds of nuts than people suspect before the test.
Perhaps just as surprisingly, some things which are called nuts or look like nuts don't particularly cause trouble in people with nut allergy. Edible chestnuts (Spanish chestnuts, marrons) are one example. Although they are called nuts and although they do cause allergic reactions in some people (especially people with latex allergy), they seem to leave people with other nut allergies in peace. Nutmeg is another very good example I'm often asked about. I have never known it cause trouble in people with nut allergy, and if it does cause the anaphylactic kind of allergy at all, it seems at the moment as if this must be very rare.
Sesame seed is particularly difficult to avoid with certainty as the seeds are so small and may fall off bakery products. It is the main ingredient of tahini (tehina, tchina), which is in turn an ingredient of other foods, for example houmous (various other spellings are used, e.g. hummus). We would like e-mail with any useful information from people who have problems with sesame seeds, poppy seed, sunflower seed, and pine kernels. It is strange that all these kinds of nuts and seeds cause problems in the same people, because peanuts, almonds and coconuts, for example, come from plants which are not closely related. The fact is that one person may be allergic to any or all of them.
Best to avoid all nuts, and to be suspicious of sesame seeds, poppy seed, sunflower seed, and pine kernels.

What is the French word for peanut? And the Spanish, Dutch or Flemish?
In English we have several quite different names: peanut, groundnut, monkey nut and names derived from the Latin name, Arachis hypogea. There are also items like peanut butter and saté sauce to consider; we haven't done so in what follows. Remember that the presence of peanuts may be taken for granted in some foods with a quite different name. Remember that restaurant staff may be temporary workers with little knowledge of the foods they serve. A patient in our area asked in a restaurant whether saté sauce contained peanut, and was told by the waiter that it did not. Of course it practically consists of peanuts.
The French also have several quite different names. Harrap's dictionary gives:
" pistache de terre
" arachide
" cacahouette
" cacaouette
Obviously there is potential for confusion. If you learn of any other names, let us know, mentioning your source of information. An email correspondent writes that French for "I am allergic to nuts" is "Je suis allergique aux noix".
Here is the same in German - "Ich bin allergisch gegen Nüsse".
In Spanish the word for peanut is cacahuete; the word for peanut butter is manteca de cacahuete or manilla; for peanut oil: aceite de cacahuete. These words are used throughout Mexico and Latin America. However, in Spain, they also say, "frutas secas" (as in dried fruits, but this refers to nuts). In addition, in both Spain and Latin America the word "nuez" (nut) is used. I am indebted to Sherree Colvin for this information. Humbert Hernandez from Gibraltar adds that in Andalucia (south of Spain) the word "avellana" is commonly used to denote peanuts, even though it actually means hazel nut.
In Pakistan, English speakers also say 'dry fruits' to refer to nuts. Surely this will be a literal translation of an Urdu expression.
Dutch names (identical spelling in Flemish):
N.B. if you are not familiar with Dutch pronunciation, don't try to predict it from English or German. E.g. 'apenoot' is absolutely not pronounced the way you would expect from English. It has three syllables, the 'a' sound is more open than the 'a' in 'father' in English, the 'e' is pronounced as a neutral vowel, and the 'oo' is like the 'o' in 'no' in English. Ask a Dutch person.
" pinda (peanut butter is pindakaas)
" aardnoot, aardnoten
" apenoot
" olienoot (given in dictionary but not to my knowledge used in everyday life)
Other languages:
It is obvious that other languages are likely to have similar complications. Get your information from a native speaker and a large dictionary (go to a public or university library), don't assume that they have remembered to tell you all the names, and don't assume you can correctly pronounce or understand the spoken versions unless you are a good speaker of the language.

Airline flights and nut snacks: how can we protect ourselves?
Some airlines have banned nuts from snacks, and others have done so on request for a particular flight when informed that a passenger was hypersensitive. Other airlines have been unhelpful. Recently there has been a death from this cause (Information from UK Anaphylaxis Campaign Newsletter, August 1997).
A mother from California e-mailed us:
"Is there any group looking to ban peanuts on airlines? I am afraid to fly with my son.
On one flight a drunk woman became upset when the stewardess requested she refrain from eating her peanuts until we landed because of my son's allergies. I have called the airline every time we fly but unfortunately, they never substitute for peanuts. I am looking for a group to help me lobby to remove peanuts from all flights."
According to the Times newspaper Sep 3 1998, p 17, col 1, the US Government Department of Transportation has told all large American airlines that they must set aside a "peanut-free zone" when requested to do so by passengers with medically documented peanut allergies. If they do not stop serving peanuts on the flight, the minimum for the "peanut-free zone" is the row of seating with the passenger plus the rows in front and behind. This is in conformity with a law passed in 1986 that guarantees access to planes for the disabled.
Plane Nuts! The story of the airline peanut- Air Travel- Date: 12 August 1998 (http://airtravel.miningco.com/library/weekly/aa081298.htm) is a website which argues that this decision by the US Government Department of Transportation (DOT ) is wrong. Clearly the author does not know anyone with serious nut allergy. The site invited votes for and against the DOT ruling.

Can peanut oil in nipple cream for breastfeeding mums cause nut allergy?
Kamilosan is a widely used breast cream for this purpose, and its formulation has recently been changed so that it now contains maize oil instead of peanut oil. The previous version has been blamed by some people for the increasing numbers of peanut-allergic children seen by doctors.
This is an interesting idea, but does not seem to fit all the facts. Other allergies such as hayfever have also increased, but pollen concentrations have not, for example. There are clearly other reasons why allergies have increased. It does not seem that the apparent increase in nut allergy parallels a historical change in the sales of Kamilosan.
Nevertheless, it seems sensible to avoid such creams which contain peanut oil, and the new version contains no nut oil.

How can I eat safely in restaurants?
Most allergic reactions to nuts happen when people are eating away from home, especially in restaurants. In our opinion, restaurants are a danger area for people with nut allergy.
Even if you explain yourself properly to the staff and don't end up eating something which has nut put in intentionally, all it takes is for someone to move a utensil from one pot to another to transfer traces (perhaps more than traces) of nut to the food you eat. In a hotel breakfast room another customer could transfer nuts from muesli to something you eat. In some oriental restaurants a garnish of crushed nuts might be added to a nut-free dish by the harassed chef, who may not have been told why you ordered a nut-free dish.
A hot curry can mask the tingling you may get in your mouth if you eat nuts you are allergic to.
If you eat in Chinese restaurants or other oriental restaurants, you are liable to eat nut sooner or later, despite your best intentions and those of the staff. One of my patients was told that saté sauce did not contain peanuts! Peanuts are of course the main ingredient. In fact non-oriental restaurants and hotels are not that safe unless they have very special arrangements in place. For example some fast food restaurants do not sell any products with nuts. Without such a precaution, there is always the possibility of cross-contamination of foods, even if you and the waiter understand each other's language properly.
Even if you tell restaurant staff the problem, they are often extremely busy. Remember, they have their own problems and may not have your rather unusual needs at the forefront of their minds every moment whilst they are handling your food. Remember that "to err is human". Remember that you make mistakes too.
Restaurant staff are increasingly aware of the problem and are in many cases now doing their best, but in most cases we feel that restaurants are inherently unsafe if you have nut allergy.
If you do eat in a restaurant, a good expression to use is:

"By the way, I must tell you that I am dangerously allergic to nuts, and if I eat anything with even the tiniest trace of nut I might die"
So don't mince words. State the extreme risk clearly if death is a risk at all, even a tiny risk.
Tasting foods to find out whether they contain nuts is not reliable.
People have died through relying on being able to tell whether food contained nuts.
Of course, NEVER EAT IN A RESTAURANT WITHOUT YOUR ADRENALINE (EPINEPHRINE) KIT. It is also far better to eat with someone who knows your problem and what to do about it.

When should I use adrenaline (epinephrine)?
Some specialists advise that adrenaline should be used for any reaction. We don't agree, but have recently changed our view somewhat. You should certainly not wait until you (or your nut-allergic child) is beginning to be incapacitated. The earlier you give the treatment, the better it works, we believe. Rapid progression of symptoms is a danger sign.
If your child gets just a few itchy swollen spots near the lips and the reaction is not getting worse, by all means have the injection at the ready and make sure you can get help quickly if things deteriorate, but if they are not deteriorating, why inject?
On the other hand, if your child is lying unconscious, with obvious difficulty in breathing, it could already be too late. So there is a right time to give adrenaline (epinephrine) and your judgement as a nonmedical person needs to be be good enough to get this right.
Our recommendation is the "3D RULE" :
1. Definite reaction to nuts: evidence of a reaction should be obvious
2. Deterioration: if the reaction is already improving by the time you get the adrenaline, wait with the adrenaline at the ready until improvement is complete and a doctor says it is safe.
3. Death a possibility realistically if the deterioration were to continue for another 5 to 10 minutes. If in doubt, give the adrenaline.
Only two things threaten life (the "2D RULE")
1. Difficult breathing whether due to swelling in the throat or to asthma. If it really seems to be just asthma, an asthma inhaler may work. But adrenaline will work in either case.
2. Deteriorating consciousness: once the child or adult patient is unconscious, life is in danger, if only from inhaling vomit, quite likely in a food allergy reaction. Make sure you know the 'recovery position' known to every competent first-aider. But prevent unconsciousness by giving adrenaline if unconsciousness seems at all likely.
Finally, (the "1D RULE")
o Do give adrenaline if in doubt!

Is nutmeg a nut? If I am allergic to nuts, will I react to nutmeg?
These two of the questions I am asked commonly. The answer is that there seems to be no special link. Allergy to nutmeg does occur, but seems to be rather rare. There has been a suggestion that there may be some cross-reaction with pollens and with celery, but the practical importance of this is not clear. If you are allergic to nuts and have never had a reaction to nutmeg it seems that nutmeg poses no greater risk than a lot of other things you are bound to eat.