A new guideline aims to bring together the latest science in order to improve the diagnosis and management of peanut and tree nut allergy1. Step-by-step algorithms help to outline the diagnostic process from clinical history to the use of both skin-prick testing and IgE testing (including the role of new nut component-specific IgE testing). The guideline, published today by the Standards of Care Committee of the British Society for Allergy & Clinical Immunology (BSACI), offers practical help to GPs that should aid triage of patients while explaining current thinking on a variety of issues.  There is also clear direction for when referral for hospital-based challenges should be considered.

A range of useful information, from advice on identifying high risk groups to details of the latest generation of allergy tests to updated advice for schools to help manage children with nut allergy, is included in a new guideline that brings together the latest thinking on the science, diagnosis and management of nut allergies.  The guideline has been developed for the medical profession using NICE-accredited processes. Published by the British Society for Allergy & Clinical Immunology (BSACI), it follows extensive consultations with allergy organisations and experts.


The introduction of a new nut allergy guideline is particularly timely, given the continued increase in the numbers of people with allergies and a rise in deaths, particularly in younger patients, since the early 1990s. Today, nut allergies are a global problem that affect over two per cent of children and one in 200 adults. Often a lifelong condition requiring constant vigilance, nut allergy may reduce quality of life even more than illnesses such as diabetes.

However, many factors have contributed to inconsistencies in diagnosis, leading to widespread confusion and mis-identification of allergy.  Some people with allergies go undiagnosed, while others unnecessarily worry or avoid nuts because of incorrectly self-diagnosed allergy. A logical, science based approach to allergy testing should be available to clearly identify every patient who may be at risk, and help improve public understanding

The new guideline seeks to add context to decision-making and give practical help to healthcare professionals, enabling them to identify and prioritise those patients most in need of further investigation in pursuit of a diagnosis and then provide appropriate ongoing support.

Arguably the most comprehensive overview on nut allergies currently available, and complete with protocols and diagnostic algorithms, the guideline covers every aspect of diagnosis and management from emergency treatment to food challenges. It also discusses cutting edge issues such as precautionary allergen labelling, early-life introduction and immunotherapy.

While directed particularly for specialist use in secondary care, most GPs find themselves dealing with food allergy concerns on a regular basis. The guideline offers them an up-to-date insight to the problem and a practical way to approach the issues.

New and updated areas covered by the guideline include:
  • Identifying high risk groups of patients (e.g. young children with severe eczema or an egg allergy) and assessing siblings
  • Advice on the most appropriate investigations to use, including the emerging area of peanut and nut IgE component testing which has the potential to offer more accurate diagnosis than ever before.
  • The latest thinking on allergy management, particularly for children, focussing on how a systematic approach that involves all caregivers – including grandparents, nurseries and schools – rather than just immediate family can help minimise accidental exposure
  • Comprehensive management plans including avoidance advice, patient specific emergency medication, treatment plan and training
  • The effective involvement of a range of specialists, including dietitians
  • The latest thinking on key areas including
    • New approaches to weaning that involve introducing peanut protein as part of the process – and that could reduce the numbers of adults with nut allergies in the future
    • Clinical trials of peanut oral immunotherapy


Dr Andrew Clark, one of the lead authors, is excited about the scope of the new guideline, which he believes will be of real benefit to those treating people with nut allergy. ‘We wanted to combine practical advice with a summary of current thinking on a range of issues, from new tests to immunotherapy – something that was urgently needed given the extensive debate on all these areas.

The next goal for healthcare providers, he says, is to promote a society-wide awareness of the need to create a better and safer environment for nut allergy sufferers. In the meantime, ensuring equality of access to the latest in diagnostic techniques must be the short-term priority.


The full guidelines can be found at :



1. Stiefel G, Anagnostou K, Boyle RJ, et al. BSACI guideline for the diagnosis and management of peanut and tree nut allergy. Clinical & Experimental Allergy 2017;47:719–739.
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