In case you are wondering, I am not quoting Gen. McAuliffe’s famous reply to a German surrender request to the surrounded 101st Airborne at Bastogne in December 1944. I am referring to peanut allergy, a leading cause of food allergy worldwide that affects about 2% of people in the U.S. Peanut allergy involves an immune system reaction to peanuts that may cause skin, gastrointestinal, respiratory, and cardiovascular symptoms, and may cause severe allergic reactions. Most patients develop peanut allergy in early childhood, and about 10% to 30% outgrow it.
Symptoms of peanut allergy usually develop within one to two hours of eating peanuts (often within minutes) and may occur after ingestion of even trace amounts. Allergic reactions may affect the skin (swelling, hives), gastrointestinal tract (vomiting, diarrhea), respiratory system (cough, wheeze), and cardiovascular system (low blood pressure or shock, also known as anaphylaxis). Anaphylaxis can be life-threatening, but death is rare (approximately one in 10 million).
Peanut allergy is diagnosed based on a history of allergic symptoms within two hours of eating peanuts, and either a positive skin prick test (a skin reaction that develops within 10 to 20 minutes after an allergist pricks a small amount of peanut protein into the surface of the skin) or a blood test that detects specific immunoglobulin E (IgE) antibodies to peanut and specific peanut proteins. First-line treatment for a severe allergic reaction is epinephrine (given by injection or nasal spray) which significantly reduces the risk of death from anaphylaxis. Repeat doses of epinephrine should be given every five to 15 minutes for patients whose anaphylaxis symptoms have not resolved. Additional medications may include antihistamines, intravenous epinephrine, and drugs to increase blood pressure. Patients in emergency departments may be given intravenous fluids.
Oral immunotherapy is an approved therapy by the US FDA for peanut allergy. This involves ingestion of gradually increasing amounts of peanut protein every two to four weeks to reach a dose equivalent of about one to two small peanuts, with daily peanut ingestion at home between visits. Oral immunotherapy successfully desensitizes about 80% of those with peanut allergy, allowing them to tolerate small amounts of peanut, but requires ongoing regular peanut ingestion and is associated with a risk of anaphylaxis of about 14%. In February 2024, the FDA approved a biologic medication (omalizumab) for peanut and other food allergies for people aged 1 year or older with qualifying levels of IgE. It is injected under the skin every two to four weeks with dosing based on the patient’s weight and IgE level. The first three doses are given in an outpatient setting to monitor for anaphylaxis, after which the medication can be taken at home. About two-thirds of patients with peanut allergy taking omalizumab are desensitized to peanuts.
In 2017, the National Institute of Allergy and Infectious Diseases issued a recommendation that peanut-containing foods should be introduced into the diet during infancy. This recommendation was based on a study reporting substantially lower rates of peanut allergy among infants with eczema and/or egg allergy who started eating peanut-containing foods at aged 4-11 months vs aged 5 years. Since the 2017 recommendation, a 2025 study reported a significant decrease in the diagnosis of peanut allergy in infants. Peanuts should not be given to infants or any young child before the eruption of molar teeth because of the risk of aspiration of nuts and fragments.
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