Tree Nut Allergy
Tree nut allergy is a common allergy among children and adults. About 0.5 to 1% of people in the U.S. have a tree nut allergy.1
A nut allergy is an immune system reaction to nut protein. Tree nuts contain many different proteins. Children with a nut allergy may be allergic to one or several nuts such as:
- Brazil nuts
- And others (full list below)
Nut allergy can be severe and life-threatening if not treated promptly. Tree nut allergy can impact a child’s emotional and mental health as well.
Children with a nut allergy must avoid eating nuts in all forms. It is possible to lead a healthy life without nuts. You can successfully manage nut allergy with knowledge, support, and resources. While there is no cure for nut allergy, this guide will help you manage nut allergy with confidence.
What are the symptoms of nut allergy?
When you have nut allergy, you need to be aware of the symptoms of anaphylaxis. Symptoms of anaphylaxis may include hives, vomiting, or trouble breathing. The treatment for anaphylaxis is injectable epinephrine.
Signs and symptoms of anaphylaxis in children, teens, and adults include:
- Skin rash, itching, hives
- Swelling of the lips, tongue, or throat
- Shortness of breath, trouble breathing, wheezing
- Stomach pain, vomiting, diarrhea
- Feeling like something awful is about to happen
Common signs and symptoms of anaphylaxis in infants and toddlers include:2
- Skin rash, itching, hives
- Swelling of the lips, tongue, or throat
- Stomach pain, vomiting, diarrhea, spitting up
- Arching back, bringing knees to the chest
- Coughing, wheezing
- Rubbing eyes, itchy or red eyes
How do doctors diagnose nut allergy?
A doctor will do a physical exam and ask questions about medical history. They will ask what happens when nuts are eaten. They may order allergy testing to help confirm the diagnosis. A skin prick test or a blood test known as a specific IgE test may be used by your doctor to diagnose this food allergy.
Your doctor may also recommend a test called an oral food challenge. This test is done by an allergist. It is the gold standard to diagnose a food allergy or confirm if your child has outgrown the allergy. Sometimes an oral food challenge is necessary when your child’s medical history is not entirely clear. Also, a positive skin or blood test to tree nuts may not mean your child is allergic to nuts. In people who do not have a clear history of having a reaction to nuts, an oral food challenge is the only way to truly confirm the allergy.
An allergy to one tree nut does not mean your child is allergic to all tree nuts. But some nuts are related. It’s common for a child to be allergic to multiple tree nuts. Talk with your child’s doctor to find out if they should avoid all tree nuts.
How can I prevent nut allergy reactions?
Tree nuts are common in foods such as cereals, granola, desserts, cookies, candies, sauces, baked goods, and breads. They are also common in plant-based and vegan foods (for example, milk-free cheese can contain cashew).
Nut allergy can cause a severe allergic reaction called anaphylaxis [anna-fih-LACK-sis]. The only way to avoid an allergic reaction is to remove the tree nuts your child is allergic to from their diet.
But you can successfully manage your nut allergy. This can be done by:
How do I read labels for nuts?
Under the Food Allergen Labeling and Consumer Protection Act (FALCPA), food companies must label their products clearly if they contain nuts. FALCPA requires companies to name the specific type of nut on the label.3
When reading labels for tree nuts, look for tree nuts to be labeled either in parentheses after an ingredient in the ingredient list or in a statement under the ingredient list. For example:
- Tree nuts (almond)
- Contains: pistachio
Sometimes nuts may appear in bold print in the ingredient list too. To avoid nuts in foods and other products, it helps to learn the different names of nuts (see our list below).
Some food companies put advisory statements on their labels. They may say “may contain hazelnuts” or “made in a facility with cashew.” FALCPA does not require these statements. They can be confusing and may not tell you the actual risk of the product. If you have questions about advisory labels, talk with your allergist.
The FDA recognizes coconut and shea nut/shea butter as tree nuts according to FALCPA. This means that if these ingredients are in a food, the label has to say it contains tree nuts. But allergic reactions to coconut and shea nut/shea butter are rare. Most people with a tree nut allergy can eat coconut and shea nut.
Some foods seem like they may be related to tree nuts but are not. For example, water chestnuts and butternut squash are vegetables. Spices like nutmeg (a seed) and cinnamon (powder from tree bark) do not come from tree nuts. These are safe for people with a tree nut allergy.
If a food item does not have a label, you can’t read it, or you have any doubts, don’t eat it. Always read the entire label every time. Food companies may change their recipes.
The FALCPA does not apply to all foods and everything that may contain nuts though. This means nuts could be “hidden” in products or listed under other names. Or you may not be able to find out the exact ingredients. These foods and products do not have to have nuts clearly listed or labeled and may contain nuts:
- Arts and crafts supplies
- Prescription and over-the-counter drugs
- Cosmetics and personal care items (such as, makeup, lotions, and soaps)
- Pet or animal food
- Food served in restaurants, cafeterias, or other food service providers
There are many different names for nuts. When shopping and cooking, have a list of the different names of nuts on hand to check food packages for nut ingredients. We have compiled a list of the different names of tree nuts below. You can also download and print Kids with Food Allergies’ (KFA) Guide to Managing Nut Allergy.
Most states in the U.S. do not have regulations regarding food allergies and restaurants. Ingredients in restaurant foods may vary. Cross-contact is also more likely. Many restaurants are becoming more food allergy aware though. Look for places that have food allergy policies and allergy menus. Give the staff a chef card that alerts them to your allergy and lists nut ingredients for them to watch for. Download and print KFA’s Tree Nut Allergy Chef Cards.
Tree nut names and ingredient list
Note: This list contains all tree nuts. Talk with your doctor about whether or not your child should avoid only the nuts they are allergic to or all nuts.
All labels should be read carefully before consuming a product, even if it has been used safely in the past.
The following is a list of “tree nuts” recognized by the FDA. If the product is an FDA-regulated food, the common tree nut name must appear on the label. Read all labels carefully before giving your child a product, even if your child has eaten it safely in the past.
Chestnut (Chinese, American, European, Seguin)
Walnut (English, Persian, Black, Japanese, California)
COMPLETE LIST OF NUT NAMES (BOTANICAL NAMES AND DERIVATIVES)
Almond – Prunus dulcis (Rosaceae), marzipan (almond paste)
Beech nut – Fagus spp. (Fagaceae)
Brazil nut – Bertholletia excelsa (Lecythidaceae)
Butternut – Juglans cinerea (Juglandaceae), Juglans spp. (Juglandaceae), white walnut, related to walnut and heartnut
Cashew – Anacardium nuts, Anacardium occidentale (Anacardiaceae)
Chestnut (Chinese, American, European, Seguin) – Castanea spp. (Fagaceae)
Chinquapin – Castanea pumila (Fagaceae)
Coconut* – Cocos nucifera L. (Arecaceae (alt. Palmae))
Filbert – Corylus spp. (Betulaceae), hazelnut
Gingko nut – Ginkgo biloba L. (Ginkgoaceae)
Hazelnut – Corylus spp. (Betulaceae), filbert, Nutella®, gianduja
Heartnut – Juglans spp. (Juglandaceae), Japanese walnut, related to walnut and butternut
Hickory nut – Carya spp. (Juglandaceae)
Lichee nut – Lychee nut, Litchi chinensis Sonn. Sapindaceae
Macadamia nut – Macadamia spp. (Proteaceae), bush nut, Queensland nut, maroochi nut, bauple nut, Hawaii nut
Pecan – Carya illinoensis (Juglandaceae)
Pili nut – Canarium ovatum Engl. in A. DC. (Burseraceae)
Pine nut/piñon nut – Pinus spp. (Pineaceae), Indian nut, piñon nut, pinyon nut, pigndi nut, pignolia nut, pignon nuts, caponata, pesto
Pistachio – Pistacia vera L. (Anacardiaceae)
Shea nut** – Vitellaria paradoxa C.F. Gaertn. (Sapotaceae), karite
Walnut (English, Persian, Black, Japanese, California) – Juglans spp. (Juglandaceae), related to butternut and heartnut
MAY CONTAIN A VARIETY OF NUTS
Mandelonas – peanuts soaked in almond, pecan, walnut, or other nut flavoring shaped to look like other nuts, Nut-Nuts®, artificial nuts, fake nuts, faux nuts
Mashuga nuts – spiced nuts
Natural nut extract – for example, almond extract
Nut butters – for example, almond butter, hazelnut butter, Brazil nut butter, macadamia nut butter, pistachio nut butter, karite butter, as well as other nut butters
Nut oil – for example, walnut oil, as well as other nut oils
Pralines – usually made with pecans but can be made with other nuts
NUTS ARE SOMETIMES FOUND IN
However, if the product is an FDA-regulated food, the common tree nut name must appear on the label.
The FDA lists coconut as a tree nut. In fact, coconut is a seed of a drupaceous fruit. Most people allergic to tree nuts can safely eat coconut. Coconut allergy is rare. If you are allergic to tree nuts, talk with your allergist before removing coconut from your diet.
** Shea nut/shea butter
The FDA lists shea nut to be a tree nut. But studies have shown that a shea nut allergy is rare.
Download or Order Print Copies:
Tree Nut Allergy Chef Cards
Is coconut a tree nut?
The FDA lists coconut as a tree nut. But most experts disagree with this. In fact, coconut is a seed of a drupaceous fruit. Most people allergic to tree nuts can safely eat coconut. Coconut allergy is very rare. If you are allergic to tree nuts, talk to your allergist before removing coconut from your diet.
If I have a nut allergy, do I need to avoid all nuts?
Some tree nuts are closely related, so if your child is allergic to one, there is a higher chance they are allergic to a related nut. Cashew and pistachios are related. Pecans and walnuts are related as well. Cross-reactivity occurs when the proteins in one food are similar to the proteins in another. When that happens, the body’s immune system sees them as the same.
Most people who are allergic to one tree nut are not allergic to all tree nuts. But your child’s doctor may recommend they avoid all tree nuts if they are allergic to one or more tree nuts. They may also recommend they avoid peanuts. Young children may have a hard time telling the difference between different nuts. It is also because it’s common for nuts to come in contact with other types of nuts during food processing. Your doctor may also recommend that your child not avoid foods unnecessarily. Eating varied foods, including nuts, supports good nutrition and may prevent a new allergy from developing.
Each person’s allergy and dietary needs are different. Ask your allergist if other nuts should be included or avoided in your child’s diet.
If my child has a nut allergy, do they need to avoid peanuts too?
Tree nuts are in a different plant family than peanuts. Peanuts are legumes and are not related to tree nuts (almonds, walnuts, cashews, etc.). However, it is fairly common to have multiple food allergies. Someone with tree nut allergy may also have peanut allergy. About 30% of people who are allergic to peanuts also react to at least one tree nut, according to studies.3 Talk with your child’s doctor about whether or not they should avoid peanuts.
What can I substitute for nuts in recipes?
It is very easy to replace nuts in a recipe. There are many seeds and seed products available including sunflower butter and pumpkin seed butter. Roasted chickpeas can replace nut snacks. You can use pretzels as a substitute for pecans in pecan pie.
Learn more: Replacing Nuts in Recipes
How can I make sure my child gets enough nutrition on nut-free diet?
Tree nuts are a good source of protein, vitamins, and minerals in a child’s diet. However, if your child needs to avoid nuts of any type, they should not be at nutritional risk since there are many other sources of protein to eat instead.
WHEN AVOIDING PEANUT
|SUGGESTED ALTERNATE SOURCES
(if not allergic)
|Protein, Vitamins, Minerals||Increase other protein foods such as meat, legumes, fish, poultry, eggs, dairy
(if safe for your child);
fruit, vegetables, and enriched grains
Will my child outgrow their nut allergy?
Tree nut allergy usually starts in childhood and more often lasts throughout a person’s life. But about 10% of people with a tree nut allergy may outgrow it.1 (This means about one out of 10 kids will have their nut allergy resolve.)
Is there a treatment for nut allergy?
Food oral immunotherapy (OIT) is a food allergy treatment that retrains your child’s immune system to respond differently to food. OIT is not a cure for food allergies. But it may allow your child to eat foods with less stress and worry. There is one FDA approved OIT treatment as of December 2022, and it is for peanut allergy.
Many allergists have been offering OIT treatment using foods in various forms, such as a liquid, flour, or the actual food itself. These methods are not approved by the FDA. Talk with your child’s allergist about the most appropriate OIT option for your child. The FDA is looking at other food allergy treatments to fast track through the approval process to address this unmet need in the food allergy community.
There are many known side effects or possible adverse reactions to OIT. Talk with your allergist to see if this treatment might be right for your child and family.
Food Allergy Fact
Peanut and tree nut allergies tend to be life-long allergies.
Medical Review: December 2022 by Michael Pistiner MD, MMSc
1. Everything You Need to Know About Tree Nut Allergy. (2020, September 28). American Academy of Allergy, Asthma & Immunology. https://www.aaaai.org/tools-for-the-public/conditions-library/allergies/everything-you-need-to-know-about-tree-nut-allergy
2. Pistiner, M., Mendez-Reyes, J. E., Eftekhari, S., Carver, M., Lieberman, J., Wang, J., & Camargo, C. A. (2021). Caregiver-reported presentation of severe food-induced allergic reactions in infants and toddlers. The Journal of Allergy and Clinical Immunology: In Practice, 9(1). https://doi.org/10.1016/j.jaip.2020.11.005
3. Center for Food Safety and Applied Nutrition. (2018). Guidance on FAQs on Food Allergens. U.S. Food and Drug Administration. https://www.fda.gov/regulatory-information/search-fda-guidance-documents/guidance-industry-questions-and-answers-regarding-food-allergens-edition-4
Ask the Allergist
Have a question on managing food allergies, asthma, other allergic conditions? Our allergist can help.