TOPLINE:

In children, multiple nut allergies were associated with a higher risk for anaphylaxis, whereas smaller wheal sizes on the prick-to-prick test predicted tolerance development. Aeroallergen sensitization, particularly to pollens, reduced tolerance acquisition in children with almond or walnut allergies.

METHODOLOGY:

• Researchers conducted a retrospective study of 121 children (mean age, 81 months; 63.64% boys) with tree nut or peanut allergies at a tertiary allergy center in Türkiye to assess clinical and laboratory features associated with anaphylaxis risk and tolerance development.
• Allergens tested were cow's milk, egg (yolk or white), wheat, soy, aeroallergens, tree nuts (hazelnut, walnut, pistachio, almond, cashew, or pecan), peanuts and other legumes (lentil, chickpea, or pea), seafood, sesame, and seeds (pumpkin or sunflower), with a mean follow-up duration of 43 months.
• Tolerance was reassessed using the prick-to-prick test and oral food challenge every 6-9 months for foods with a higher likelihood of tolerance (eg, milk and eggs) and at least every 18-24 months for more persistent allergens such as peanuts and tree nuts.

TAKEAWAY:

• Multiple nut allergies were more common in patients with pistachio (P < .001), almond (P < .001), hazelnut (P = .002), or cashew (P = .042) allergies. Multiple nut allergies carried a higher risk for anaphylaxis than single nut allergies (P = .031).
• During follow-up, 25% of patients developed tolerance, whereas 13% continued to experience anaphylaxis; hazelnut (67%) and pistachio (62%) were the most common triggers.
• Aeroallergen sensitization halved tolerance rates for almond allergy (from 66% to 33%; P = .035) and reduced walnut tolerance from 62% to 37% (P = .04).
• Smaller wheal sizes at diagnosis for hazelnut, cashew, and pistachio were associated with tolerance acquisition (P = .03, P = .015, and P = .028, respectively).

IN PRACTICE:

"Our findings suggest that the risk of anaphylaxis may vary by nut type and age," the authors wrote. "Multiple nut allergy and aeroallergen sensitization — particularly in almond and walnut allergies — were associated with more severe reactions and lower tolerance, highlighting the need for close monitoring," they added. 

SOURCE:

Damla Baysal Bakır, MD, with Dokuz Eylül University, Izmir, Türkiye, was the corresponding author of the study, which was published online on September 10, 2025, in International Archives of Allergy and Immunology. 

LIMITATIONS:

The single-center design, small sample size, variable follow-up duration, incomplete oral food challenge protocols, and absence of specific immunoglobulin E, basophil activation test, or component-resolved diagnosis data may have limited the analysis.

DISCLOSURES:

The authors declared having no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.