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Tree Nut Allergy

Tree nut allergy is one of the most common food allergies in children and adults.  Like peanuts, tree nuts (almonds, cashews, walnuts, etc.) tend to cause particularly severe reactions, even if a person is exposed to only a tiny amount. 

In a registry of 5,149 people who had peanut or tree nut allergy, the median age of reaction to tree nuts was 36 months.  Sixty-eight percent of the tree nut-allergic participants were not aware of any previous exposure to tree nuts before their first reaction.  This allergy tends to be life-long; recent studies have shown that approximately 9% of tree nut-allergic children eventually outgrow their allergy.  

People seldom are allergic to just one type of tree nut, so allergists usually will tell patients to avoid all tree nuts.

How to Avoid Tree Nuts*
The federal Food Allergen Labeling and Consumer Protection Act (FALCPA) requires that any packaged food product that contains tree nuts as an ingredient must list the specific tree nut on the label.  Please be sure to read all product labels carefully before purchasing and consuming any item. Remember, also, that ingredients change from time to time, so check labels every time you shop.  If you are still not sure whether or not a product contains tree nuts, call the manufacturer. Always take extra precaution when dining in restaurants or eating foods prepared by others. If you are in doubt about any product or dish, don’t eat it.

The following common nuts are considered tree nuts under U.S. law: almond; Brazil nut; cashew; chestnut; filbert/hazelnut; macadamia nut; pecan; pine nut (pignolia nut); pistachio; walnut.

The following are uncommon, additional tree nuts that require disclosure by U.S. law.  However, the risk of an allergic reaction to these nuts is unknown: beechnut; ginkgo; shea nut; butternut; hickory; chinquapin; lychee nut; pili nut; coconut. The American Academy of Allergy, Asthma and Immunology (AAAAI) states: "There is conflicting information on whether or not coconut must be avoided by tree nut allergic individuals. In the past, coconut has not been considered a tree nut and typically has not been restricted in the diets of people with a tree nut allergy. Coconut is in the palm family and it is actually the seed of a drupaceous fruit, not a tree nut. It does not cross-react with tree nuts. However, in October 2006, the FDA began to define coconut as a tree nut.There are a small number of documented cases of allergic reactions to coconut. However, most occurred in individuals who were not allergic to other tree nuts. Thus, it is possible to be allergic to coconut, although coconut does not cross-react with tree nuts. It is important to discuss this issue with your allergist/immunologist who can instruct you on whether or not you need to avoid coconut if you are tree nut allergic."

• Tree nut proteins may be found in cereals, crackers, cookies, candy, chocolates, energy bars, flavored coffee, frozen desserts, marinades, barbeque sauces, and some cold cuts, such as mortadella. 
• Tree nut protein will be found in foods such as gianduja (a creamy mixture of chocolate and chopped almonds and hazelnuts, although other nuts may be used); marzipan (almond paste); nougat; Nu-Nuts® artificial nuts; pesto; and nut meal.
• Tree nut oils may contain nut protein and should be avoided.
• Ethnic restaurants (e.g., Chinese, African, Indian, Thai, and Vietnamese), ice cream parlors, and bakeries are considered high-risk for people with tree nut allergy due to the common use of nuts and the possibility of cross contamination, even if you order a tree-nut-free item.
• Avoid natural extracts, such as pure almond extract and natural wintergreen extract (for the filbert/hazelnut allergy).  Imitation or artificially flavored extracts generally are safe.
• The following are not considered nuts:  nutmeg, water chestnuts, and butternut squash.
• Tree nut oils are sometimes used in lotions and soaps.  Shea nut, although not usually found in food products, is often used in lotions.
• Some alcoholic beverages may contain nut flavoring and should be avoided.  Since these beverages are not currently regulated by FALCPA, you may need to call the manufacturer to determine the safety of ingredients such as natural flavoring.

* FAI wishes to thank the Jaffe Food Allergy Institute at Mount Sinai School of Medicine (New York, NY) for providing  the allergen avoidance information in this article.