Tree Nut Allergy: What You Should Know

Tree nut allergies are one of the 9 most common food allergies. The most common tree nut allergies are walnut, almond, hazelnut, pecan, cashew, and pistachio (1). It’s possible to be allergic to only 1 kind of nut, but about half of kids who are allergic to 1 nut are also allergic to another.

Tree nut allergies are usually lifelong with only about 9% of children outgrowing their allergy (1). The proteins in the nut trigger an immune response that can produce mild or severe reactions.

Because they are one of the top 9 allergens, tree nuts are required to be labeled on food packages. The label needs to state the specific type of nut.

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What is a Tree Nut?

As the name suggests, tree nuts are nuts that grow on trees. For the purpose of allergies, the FDA lists almond, brazil nut, cashew, hazelnut, macadamia nut, pecan, pine nut, pistachio, walnut, beech nut, butternut, chestnut, chinquapin, ginkgo nut, hickory, lychee, pili nut, and shea nut as the tree nuts to avoid. Coconut was also added, although many people who are allergic to coconut are not allergic to other tree nuts.

Tree Nut vs Peanut

Tree nuts are very different from peanuts. Peanuts are legumes that grow underground, not actually nuts. Around 40% of children with a tree nut allergy also have a peanut allergy.

How to Introduce Tree Nuts

Most research and guidelines for allergen introduction is done on peanuts, but has been extrapolated to the other allergens. While it’s not recommended to give kids whole nuts until age 4, early introduction of allergens has been shown to reduce the incidence of food allergies (2). Depending on whether or not your child is at high risk for developing allergies, you may want to introduce between 4-6 months or at 6 months.

As with other allergens, introduce tree nuts as the only new food that day. If you are looking for a more comprehensive guide to introducing allergens, check out my Allergy Introduction Handbook. Please note that some of these suggestions include other allergens (indicated with a *).

  • Smooth nut butter mixed into baby cereal
  • Pesto made with walnuts instead of pine nuts
  • Smooth nut butter thinly spread on toast* strips
  • Banana muffins* (sub alternative nut butters for peanut butter)
  • Crushed nuts as coating on a banana or avocado
  • Smooth nut butter diluted with breastmilk or formula

Diagnosis

The gold standard for the diagnosis of a food allergy is an oral challenge. While scary, it’s actually an easy test to perform: if the child eats the allergen, do they consistently produce a reaction? If so, they are allergic. Then, to confirm a diagnosis, a doctor may use a blood test or skin prick test. A medical professional should always make the diagnosis, because a self-diagnosis can lead to unnecessary restriction.

How to Avoid Tree Nuts

Unfortunately, it may not be as simple as just not eating nuts. Tree nuts can come into contact with other foods during processing. There can be cross-contact in the kitchen if the cook touches nuts or a nut product and then cooks another dish.

It’s very important to always check food labels. Companies must list nuts clearly on the ingredients list in plain language or under the label in a statement that reads “Contains nuts.” They must also specify which type of nut they are using.

Places to Check

Always ask about ingredients in foods that you did not make yourself. When eating at a restaurant, there is always a risk of cross-contact, so it is important to make it very clear that there is an allergy.

Some alternative nut options (such as sunflower butter) are made on shared equipment with tree nuts and peanuts. If you plan on using these products, you can contact the manufacturer to determine whether these products will be safe.

Sometimes companies will use walnut shells in natural sponges or brushes.

Other Names for Tree Nuts

These terms mean that tree nuts may be present:

  • Almond
  • Artificial nuts
  • Beech nut
  • Black walnut hull extract
  • Brazil nut
  • Butternut
  • Cashew
  • Chestnut
  • Chinquapin nut
  • Coconut
  • Filbert
  • Gianduja
  • Ginkgo nut
  • Hazelnut
  • Hickory nut
  • Litchi/lichee/lychee nut
  • Macadamia nut
  • Marzipan/almond paste
  • Nangai nut
  • Natural nut extract (artificial extracts are generally safe)
  • Nut butters or oils
  • Nut meal/meat/milk/paste/pieces
  • Pecan
  • Pesto
  • Pili nut
  • Pine nut
  • Pistachio
  • Praline
  • Shea nut
  • Walnut
  • Walnut hull extract

Reactions to Tree Nuts

A reaction to nuts via the skin or air is not common. However, if a child gets nut butter on their hands and then touches their eyes or puts their fingers in their mouths, it could cause problems.

Although reactions can range from mild to severe, it is usually recommended for all kids with nut allergies to have an epi-pen with them at all times. Epinephrine is used to treat anaphylaxis, a severe reaction to allergies.

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