The ability of children and families with and without nut allergy to correctly identify nuts

which must be identifiable and distinguishable from the index nut(s). Strengths of this study are the inclusion of children and guard-ians from both groups and postsurvey follow-up. Unlike previous studies, we included chopped nuts, which may constitute the highest risk of misidentification for PN-and TN-allergic subjects. Most PN-allergic children could identify peanuts in shell better than out of shell or chopped peanuts. This suggests educational imagery may need to include more informative and realistic pictures of various forms of nuts.


The ability of children and families with and without nut allergy to correctly identify nuts
To the Editor, Peanut (PN) and tree nut (TN) allergies are common, and severe allergic reactions may occur. Current management of PN and TN allergy is patient and family education on strict avoidance measures and the use of medication to treat accidental exposures, and in some cases oral immunotherapy. Historically, nut-allergic patients were advised to avoid all nuts. While this may have simplified family treatment plans, it imposed unnecessary dietary restrictions. In current practice, allergists recommend the introduction of nuts they deem safe to the child's 'in-home' diet, but practice varies internationally. 1 This presents an important safety issue for patients and their families. Safe introduction of nuts at home should involve children and their guardians carefully reading labels on packages. An ability to recognise individual nuts by sight would further increase a child's safety.
We hypothesised children with PN/TN allergies, and their families would be better than the general public at nut identification.
However, previous studies have shown people with PN/TN allergy may not be better at identifying nuts than control groups. [2][3][4][5] We conducted a cross-sectional study of 126 child and guardian pairs (63 cases and 63 controls). Cases included children ≥5 years of age with PN and/or TN allergy and their guardians. Children of a similar age without a nut allergy and their guardians were selected from other paediatric clinics in the same two hospitals as the control group. Children with learning or communication impairment and families unable to give written informed consent in English were excluded. We aimed to identify and compare the level of nut knowledge between the cases and controls. A secondary aim was to evaluate self-reported knowledge scores in the nut-allergic group pre and postsurvey.
Participants were asked to examine 22 specimen jars, each containing one of 8 nut types in one of 3 forms: 'in-shell' (except cashew which does not have a shell and Brazil, which we could not source in shell), 'out of shell' and in 'chopped' form ( Figure 1). No touching of the jars was allowed. Child and guardian answers were completed independently. Participants were asked to rate their nut knowledge on a Likert scale from 1 to 10 before taking the quiz. A follow-up telephone questionnaire consisting of eight questions was conducted with the nut-allergic cohort. Participants were again asked to rate their nut knowledge from 1 to 10. We considered the potential negative effects of the survey included over-confidence leading to a change in safe allergen avoidance measures such as label checking.
At follow-up, we asked participants if they had changed their allergen trigger avoidance behaviours because of the study.
Data analysis was performed using StataSE 17.0. Appropriate descriptive statistics were used to describe the cohort and appropriate parametric, and non-parametric tests were used to compare the groups. p-values have been corrected 6 to account for multiple comparisons and reduce the risk of type 1 error.
Two hundred and fifty two participants were recruited to the study: 63 child and guardian pairs in each group. Fifty child and guardian pairs in the allergic group (79%) completed the follow-up questionnaire.
The mean age was 10 years for the nut-allergic group (38% <10 years; 62% >10 years) and 10.8 years for the control group (35% <10 years; 65% >10 years). 33% of children with nut allergy reported a nut-free diet compared with 20% of the control group.
No participant correctly identified all 22 nuts displayed (Table 1).
There was no significant difference between children and guardians with and without nut allergy. Guardians in both groups scored higher than their children, with a median score 12 and 10 for nut-allergic and control parents respectively compared with a median score of 3 for both child cohorts (p < .001). In our cohort, guardians of children with nut allergy were not better at identifying nuts than the control children and guardian group. This is a safety gap that needs to be addressed by allergists, who often advise careful introduction of likely tolerated nuts,

Key messages
• We assessed nut recognition in children with and without nut allergy and their parents/guardians.
• Parents and Guardians recognised nuts more reliably than children, but mistakes were common in both groups.