Guideline sources The following summarized guidelines for the evaluation and management of peanut allergy are prepared by our editorial team based on guidelines from 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 2020), the American Academy of Allergy, Asthma & Immunology (AAAAI/ACAAI 2020; 2014), the British Society for Allergy and Clinical Immunology (BSACI 2017), the National Institute of Allergy and Infectious Diseases (NIAID 2017), the American Academy of Dermatology (AAD 2014), and the European Academy of Allergy and Clinical Immunology (EAACI 2014). 1 2 3 4 5 6 7 8 9 10 Guidelines 1. Screening and diagnosis Diagnosis: https://web.pathway.md/diseases/rectShv16Ft0S2jfE 1/8 6/29/23, 10:56 PM Peanut allergy Pathway 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. C As per AAAAI 2014 guidelines, determine whether the reported history of food allergy, which often proves inaccurate, and laboratory data are sufficient to diagnose food allergy or whether an oral food challenge is necessary. A As per ACAAI 2014 guidelines, obtain specific IgE tests (skin prick tests, serum tests, or both) as diagnostic tools, but do not establish a diagnosis of food allergy solely based on test results. B 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). B Show 2 more 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. B 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. C Indications for testing: As per ACAAI 2020 guidelines: Consider obtaining peanut allergy testing with in patients with a physician-judged high or moderate pretest probability of peanut allergy. C Avoid obtaining diagnostic testing in patients with a low or very low pretest probability of peanut allergy. D As per AAAAI 2014 guidelines, evaluate the patient for possible peanut allergy recognizing that a relatively small number of allergen can cause a high proportion of food allergy. B As per AAD 2014 guidelines, consider obtaining peanut allergy testing in patients < 5 years of age with moderate-to-severe atopic dermatitis and either: persistent atopic dermatitis despite optimized treatment reliable history of immediate reaction after ingestion of peanuts or peanut-containing food. B Serum immunoglobulin E: As per ACAAI 2020 guidelines, consider obtaining serum-specific IgE testing for peanut allergy in patients with a physician-judged high pretest probability of peanut allergy. C Show 4 more https://web.pathway.md/diseases/rectShv16Ft0S2jfE 2/8 6/29/23, 10:56 PM Peanut allergy Pathway As per BSACI 2017 guidelines: Recognize that the magnitude of a peanut-specific IgE result relates to the probability of clinical allergy but not to clinical severity. B Regard peanut-specific IgE level of 15 KU/L as highly predictive of clinical allergy. Interpret test results in the context of the clinical history. A As per ACAAI 2014 guidelines: Obtain serum specific IgE in patients with suspected peanut allergy. B Consider obtaining component-resolved diagnostic testing to peanut allergens. B Do not routinely obtain serum total IgE levels for the diagnosis of peanut allergy. D Skin prick test: As per ACAAI 2020 guidelines, consider obtaining skin prick test for peanut allergy in patients with a physician-judged high pretest probability of peanut allergy. C Show 3 more As per BSACI 2017 guidelines: Recognize that the magnitude of a skin prick test result relates to the probability of clinical allergy but not to clinical severity. B Regard skin prick test of 8 mm as highly predictive of clinical allergy. Interpret test results in the context of the clinical history. A Intradermal skin test: do not perform intracutaneous testing for the diagnosis of food allergy. D Food challenge testing: As per BSACI 2017 guidelines, consider obtaining diagnostic food challenge testing to confirm or refute the diagnosis of peanut allergy when history and test results are conflicting. C As per ACAAI 2014 guidelines, consider obtaining oral food challenge testing to aid in the diagnosis of peanut allergy. B Show 2 more Other tests: do not obtain allergen-specific IgG measurement, cytotoxicity assays, applied kinesiology, provocation neutralization, and hair analysis for the evaluation of peanut allergy. D 4. Medical management General principles: As per AAAAI 2020 guidelines, develop a written anaphylaxis emergency care plan for patients in times of emergency. E As per BSACI 2017 guidelines: Provide patients with a comprehensive management plan including avoidance advice, patient-specific emergency medication and an emergency treatment plan, and training in administration of emergency medication. Provide regular retraining. B Manage comorbidities, especially asthma, rhinitis and eczema. https://web.pathway.md/diseases/rectShv16Ft0S2jfE 3/8 6/29/23, 10:56 PM Peanut allergy Pathway Immunotherapy: As per WMS 2022 guidelines, consider offering desensitization therapy in patients with a history of anaphylactic reactions to peanuts. B As per BSACI 2017 guidelines, consider offering peanut oral immunotherapy to induce desensitization in pediatric patients with peanut allergy. B Epinephrine autoinjectors: As per AAAAI 2020 guidelines, prescribe two epinephrine autoinjectors in case anaphylaxis occurs. E As per ACAAI 2014 guidelines: Administer epinephrine as first-line therapy for the treatment of anaphylaxis. B Ensure that self-injectable epinephrine is readily available to the patient and instruct the patient, caregiver, or both, on the importance of its use and self-administration, as relevant. B As per EAACI 2014 guidelines, consider prescribing at least one epinephrine autoinjector with any of the following additional factors, especially if > 1 is present: previous mild-to-moderate allergic reaction to peanut and/or tree nut C teenager or young adult with peanut allergy C remote from medical help and previous mild-to-moderate allergic reaction to peanut C previous mild-to-moderate allergic reaction to traces of peanut. C As per EAACI 2014 guidelines, consider prescribing epinephrine autoinjectors in patients with mild-to-moderate allergic reaction to peanut and/or tree nut, mild-to-moderate reaction to very small amounts of peanut, and in specific high-risk groups, such as adolescents, young adult males, poor access to medical care. C 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. B As per NIAID 2017 guidelines, advise strict avoidance from peanut in children identified as allergic to peanut. A As per ACAAI 2014 guidelines, prescribe a targeted allergen elimination diet as the treatment for known or strongly suspected peanut allergy. Educate about proper food preparation and the risks of occult exposure. B 6. Specific circumstances Patients with food-dependent exercise-induced anaphylaxis: Suspect food-dependent exercise-induced anaphylaxis when ingestion of causal food and tempPO 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. B https://web.pathway.md/diseases/rectShv16Ft0S2jfE 4/8 6/29/23, 10:56 PM Peanut allergy Pathway 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. B Patients with pollen-food syndrome: As per BSACI 2017 guidelines, recognize that pollen-food syndrome is a distinct disorder, usually mild, with oral/pharyngeal symptoms, in the context of hay fever or pollen sensitization, which can be triggered by nuts, and can usually be distinguished clinically from primary nut allergy. As per ACAAI 2014 guidelines: Consider diagnosing oral allergy syndrome (pollen-food allergy) and obtaining specific IgE testing to pollens in patients experiencing limited oropharyngeal symptoms after ingestion of food antigens that cross-react with pollen antigens. B Manage pollen-food allergy syndrome or oral allergy syndrome by dietary avoidance of food antigens. B Patients with food protein-induced enterocolitis syndrome: use the patient's medical history, response to a trial of elimination of the suspected food, and oral food challenge to establish a diagnosis of food protein-induced enterocolitis syndrome. Consider establishing the diagnosis based on a convincing history indicating hypotensive episodes or multiple reactions to the same food and absence of symptoms when the causative food is eliminated from the diet. B Show 4 more 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 https://web.pathway.md/diseases/rectShv16Ft0S2jfE 5/8 6/29/23, 10:56 PM Peanut allergy Pathway avoid sharing plates with other co-diners consider dining at off-peak hours. E As per ACAAI 2014 guidelines, advise patients with tree nut allergy about the risk of ingestion of similar cross-reacting foods, such as other tree nuts (walnut and pecan or pistachio and cashew). B Show 4 more 8. Preventative measures Breastfeeding: encourage exclusive breastfeeding for the first 4-6 months of life for the prevention of food allergy. B Peanut introduction: As per CSACI 2021 guidelines, introduce peanut-containing products in all infants, irrespective of their relative risk of developing peanut allergy, starting around 6 months of life, though not before 4 months of life. Introduce peanut-containing products at home when the infant is developmentally ready for complementary food introduction, in accordance with the family's cultural practice, but not before the infant demonstrates developmental readiness with eating a few other common starter foods. B Show 2 more As per NIAID 2017 guidelines, introduce age-appropriate peanut-containing food in infants with severe eczema, egg allergy, or both, as early as 4-6 months of age to reduce the risk of peanut allergy. Introduce other solid foods before peanut-containing foods to show that the infant is developmentally ready. B Show 3 more Probiotics: do not use probiotic or prebiotic supplementation in the maternal or infant diet as a means to prevent food allergy. D 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. B 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). B 10. Quality improvement School policies: ensure that all staff within the school and early years setting receive appropriate training in managing an allergic reaction. B https://web.pathway.md/diseases/rectShv16Ft0S2jfE 6/8 6/29/23, 10:56 PM Peanut allergy Pathway Show 2 more Restaurant policies: Ensure that restaurant policies include the following: ask all patrons whether there are any food allergies to be aware of clear communication with patron and chef is of utmost importance recognize signs and symptoms of anaphylaxis, and how to respond consider training on food allergy and emergency preparedness in the restaurant setting for all restaurant staff, ideally be repeated and reinforced regularly recognize that food-allergic reactions can occur through minimal cross-contact of allergen use effective cleaning methods to remove potential food allergens consider designating a special area in kitchen for preparing allergen-free meals consider designating a separate pickup area for allergen-free meals consider having dedicated, color-coded equipment for allergen-free meals consider creating menus with clear ingredient lists and update accordingly consider using computer technology to help filter menu depending on food item, or to create food allergy alerts. E Clinical findings Patient demographics Symptoms Children Abdominal pain Change in voice Past medical history Chest pain Chest tightness Allergic rhinitis Cough Anaphylaxis Diarrhea Asthma Dizziness Atopic dermatitis Fainting Atopy Hoarseness Food allergy Itchy rash Pollen-food allergy syndrome Lip swelling Tree nut allergy Nasal congestion Ocular exam Rhinorrhea Shortness of breath Conjunctival injection Skin flushing Tearing Sneezing Throat swelling Respiratory exam Vomiting Wheezing Vital signs Serological findings Hypotension serum arachis hypogaea 2- specific IgE Tachycardia serum peanut-specific IgE Head and neck exam https://web.pathway.md/diseases/rectShv16Ft0S2jfE 7/8 6/29/23, 10:56 PM Peanut allergy Pathway Periorbital edema Integument exam Angioedema Skin erythema Urticaria Diagnostic procedures peanut skin prick test References 1. G Stiefel, K Anagnostou, R J Boyle et al. BSACI guideline for the diagnosis and management of peanut and tree nut allergy. Clin Exp Allergy. 2017 Jun;47 6 719 739. Open 2. Alkis Togias, Susan F Cooper, Maria L Acebal et al. Addendum Guidelines for the Prevention of Peanut Allergy in the United States: Report of the National Institute of Allergy and Infectious Diseases- Sponsored Expert Panel. Pediatr Dermatol. 2017 Jan;34 1):e1-e21. Open 3. Cristina A Carter, Michael Pistiner, Julie Wang et al. Food Allergy in Restaurants Work Group Report. J Allergy Clin Immunol Pract. 2020 Jan;8 1 70 74. Open 4. Matthew Greenhawt, Marcus Shaker, Julie Wang et al. Peanut allergy diagnosis: A 2020 practice parameter update, systematic review, and GRADE analysis. J Allergy Clin Immunol. 2020 Dec;146 6 1302 1334. Open 5. Hugh A Sampson, Seema Aceves, S Allan Bock et al. Food allergy: a practice parameter update-2014. J Allergy Clin Immunol. 2014 Nov;134 5 1016 25.e43. Open 6. David M Fleischer, Edmond S Chan, Carina Venter et al. 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EAACI food allergy and anaphylaxis guidelines: diagnosis and management of food allergy. Allergy. 2014 Aug;69 8 1008 25. Open https://web.pathway.md/diseases/rectShv16Ft0S2jfE 8/8