1

PEANUT ALLERGY AND ANAPHYLAXIS IN CHILDREN

An Integrative Review: Peanut allergy and Anaphylaxis in Children

Harrison Black
Bon Secours College of Nursing
Nursing Research
NUR 4122
Dr. Perkins
Date Due: December 1, 2015

I pledge.

PEANUT ALLERGY AND ANAPHYLAXIS IN CHILDREN

Abstract
The goal of this integrative review is to evaluate the literature regarding the severity of
peanut allergy in children compared to that of any other food allergy and to evaluate if the
children with the peanut allergy are at greater risk for anaphylaxis. Peanut allergy seems to be
one of, if not the most dangerous food allergies one can have. The research design is an
integrative review. The search for the literature was done using the search engine PubMed and
the search yielded 19 results in which 5 nursing articles were chosen to complete this integrative
review. The results and findings analysis of the five articles demonstrated support for an increase
in stronger patient education and the correct and timely use of epinephrine autoinjectors.
Limitations to this review include; the limit on the number of articles that were allowed to be
used, the articles had to be published between 2010 and 2015, the experience of the researcher,
and the time limit in which to complete the review. Future research should include ways to
improve patient education and the correct and timely use of epinephrine autoinjectors.

PEANUT ALLERGY AND ANAPHYLAXIS IN CHILDREN

An Integrative Review: Peanut Allergies and Anaphylaxis in Children

The purpose of this integrative review is to analyze the literature having to do with
incidents of anaphylaxis in children under 18 years of age who also have a peanut allergy.
Research indicates that peanut allergies cause anaphylaxis in children more than any other food
allergy (Cherkaoui et al., 2015). Some key interventions to decrease the incident of anaphylaxis
include clearer instructions on the timely and correct use of epinephrine autoinjectors and
additional comprehensive education for caregivers and children about peanut allergy. Peanut
allergies are an area of interest for the researcher as a nursing student studying pediatric
medicine. Additional information about peanut allergies, a common childhood allergy, has helped
the researcher prepare for pediatric coursework and pediatric clinical experiences. The proposed
PICO question by this researcher is as follows: Are patients with a peanut allergy, compared to
those with any other allergy, at greater risk for anaphylaxis between the ages of 0-18 years?
Research Design, Search Methods, & Search Outcomes.
The articles used for this integrative review were retrieved from the computer-based
search engine called PubMed. The search keywords included, children, peanut, peanut
allergy, and anaphylaxis. This search yielded 19 results with the full free text box checked
in the search criteria. The researcher initially thought this number to be quite low, but the search
yielded acceptable results. To maintain relevancy and timeliness, the articles were limited to peer
reviewed nursing research articles, written in English, between the years 2010-2015. These
articles had to be closely related to the researchers PICO question, Are patients with a peanut
allergy compared to those with any other allergy at greater risk for anaphylaxis between the ages
of 0-18 years? Articles were selected based on inclusion criteria. The inclusion criteria included:
peanut allergy, children, anaphylaxis and peanut. Articles that did not meet this inclusion criteria

PEANUT ALLERGY AND ANAPHYLAXIS IN CHILDREN

were excluded from the review. This process produced five nursing articles, one that had both
qualitative and quantitative aspects and four that were only quantitative in nature.
Findings/Results
The five articles that were reviewed show an indication that patients with a peanut
allergy, compared to those with any other food allergy, may be at greater risk for anaphylaxis
between 0-18 years of age (Abdurrahman et al., 2013; Cherkaoui et al., 2015; Liew et al., 2012;
Wainstein & Saad, 2015; & Xu et al., 2011). Four of the articles were quantitative and one was
both qualitative and quantitative in nature. A synopsis of the compiled research articles is
presented in Table 1. The research revealed why there may be an increase of incidents of
anaphylaxis in this age range. Due to this finding, the researcher framed the review according to
the following two themes regarding the possible reasons for increased incidents of anaphylaxis:
inadequate patient education regarding the allergy and the lack or untimely use of epinephrine.
The researcher is aware that the theme, lack or untimely use of epinephrine could be included
under the theme inadequate patient education however, the misuse of epinephrine was
specifically noted so numerously that the researchers decided to make it a theme.
Inadequate Patient Education Regarding the Peanut Allergy
There was a consensus among all five studies that inadequate patient information was a
contributing factor to having a greater risk for anaphylaxis (Abdurrahman et al., 2013; Cherkaoui
et al., 2015; Liew et al., 2013; Wainstein & Saad, 2015; Xu et al., 2011). However, there was one
quantitative study that only mentioned it as an accidental finding after reviewing many patients
charts and did not specifically state inadequate information as a contributing risk factor
(Wainstein & Saad, 2015). In the literature review the researchers note that peanut allergy may
be one of the most dangerous types of food allergy. In this study they found that children with a

PEANUT ALLERGY AND ANAPHYLAXIS IN CHILDREN

history of mild to moderate allergic reactions to peanuts showed an increase in more serious
reactions and/or reduced thresholds upon re-challenging the allergy a year later. They used a nonprobability sampling method and were somewhat limited by having a small sample size of only
26 children. The measurement tool and data collection method was oral food challenges and data
analysis was accomplished by using the chi-square test and t-test. The statistical analysis showed
a p-value of <0.05 which is statistically significant. This study revealed that 81% of their sample
size had an increase in symptom severity and decrease in reaction threshold, meaning it took a
smaller amount of peanuts to produce a reaction. Two of the 26 participants had an anaphylactic
reaction. While the researchers did not say it was a major factor, they did mention a noticeable
amount of patient charts had a need for further education regarding their peanut allergy in some
form. Due to the researchers findings, this study grants useful knowledge to the body of
literature emphasizing the potential for anaphylactic reactions in children between the ages of 018.
The non-probability, longitudinal study by Cherkaoui et al. (2015) sought information
regarding accidental exposures to peanuts in allergic children. They looked at severity,
management, location, and identified associated factors concerning accidental exposures. Their
tool and method of measurement was the use of a survey and statistical analysis was done using
Stata, version 13. This study claims to be the largest longitudinal study on the rate and treatment
of accidental exposures in children with a peanut allergy with a cohort of 1941 children. Of this
sample size 377 children had moderate to severe accidental exposures. One of their conclusions
was that inadequate education was given to caregivers and children regarding the strict
avoidance of the allergen. Due to the researchers findings, this study contributes to the body of

PEANUT ALLERGY AND ANAPHYLAXIS IN CHILDREN

research concerning inadequate patient education as a cause for anaphylaxis in children with a
peanut allergy.
In a study that had both quantitative and qualitative aspects, Xu et al. (2014) looked at all
causes of anaphylaxis in Ontario in order to determine trends in mortality including cause of
death and other associated factors. In this retrospective case-series analysis the researchers
quantitative data was analyzed using descriptive statistics and frequency analysis using SPSS,
while their qualitative data was analyzed using grounded theory methodology. By reviewing the
coroners database they found that food caused anaphylaxis lead to the greatest number of deaths
with peanuts as the leading allergen compared to other foods such as tree nuts, seafood, milk,
peaches, berries, grape juice, beer, tomatoes, sesame seed, and MSG. One potential weakness of
this study is that they may have underestimated the number of deaths caused by anaphylaxis by
not including deaths caused by asthma in their search of the coroners database. Two conclusions
were drawn from their findings that help support the idea that lack of education is a cause for
anaphylaxis in children. They state that education can be improved in area of food service.
Serious reactions often occur outside the home in public places such as restaurants, food courts,
or any place that sells food. They state that food can be better labeled to help buyers realize what
potentially dangerous allergens are in the ingredients. In the healthcare system it was revealed
that epinephrine administration was delayed in hospital setting, leading the researchers to believe
that more education is needed in this setting as well to help staff better manage acute allergic
reactions. Due to the researchers findings, this study contributes to the body of research
concerning inadequate patient education as a cause for anaphylaxis in children with a peanut
allergy.

PEANUT ALLERGY AND ANAPHYLAXIS IN CHILDREN

In a retrospective study of Singaporean children, Liew et al. (2013) had the objective to
describe clinical features, causative agents and management of children with anaphylaxis. Their
sample consisted of 98 children. They found that food caused anaphylaxis lead to the greatest
number of anaphylaxis cases, with peanuts representing 19% of the sample as the leading food
allergen compared to other foods such as eggs at 12%, shellfish at 10%, and birds nest also at
10%. The data analysis tool used was the chi-square test or Fishers exact test. The MannWhitney U test or Student t test was used to compare parametric and non-parametric data. The pvalue was <0.05 which was considered statistically significant. One limitation to this study is that
there may be a referral bias due to slightly less severe cases of anaphylaxis being treated in the
community. The researchers admit that the prevalence in Singapore is lower than in Western
countries but there is still low public awareness and almost a complete absence of labeling and
regulation. Due to this factor the researchers recommend a significant increase in patient
education to help bridge the gap.
The final article is a qualitative article that looked at the lived experience of encountering
an allergic reaction to food for the first time by the caregivers of children who have an allergy
(Abdurrahman et al., 2013). The sample size of this study consisted of 184 caregivers. They
hypothesized that insufficient knowledge of the food allergy would be a large barrier to getting
adequate care and coping, while at the same time being a source of fear and anxiety. In this
mixed methods study the chosen tools of measurement were interviews and a survey. The
qualitative analysis was guided by the constant comparative method of grounded theory
methodology. One of the major themes drawn from the interviews and surveys was the lack of
education about the avoidance, recognition of an allergic reaction event, and anaphylaxis
management. Due to the researchers findings, this study contributes to the body of research

PEANUT ALLERGY AND ANAPHYLAXIS IN CHILDREN

concerning inadequate patient education as a cause for anaphylaxis in children with a peanut
allergy.
The Lack or Untimely use of Epinephrine
All five research studies mentioned the lack or untimely use of epinephrine
(Abdurrahman et al., 2013; Cherkaoui et al., 2015; Liew et al., 2013; Wainstein & Saad, 2015;
Xu et al., 2011). In one recent quantitative study by Wainstein & Saad (2015) they state in their
literature review that it is an accepted medical practice for all peanut allergic individuals to be
prescribed an epinephrine autoinjector even if there is no prior history of anaphylaxis.
In a quantitative, retrospective case-series analysis by Xu et al. (2011) one of their
conclusions is that there is a big gap in epinephrine autoinjector education. They found that
educational need is largest for asthmatics and food allergic teens, especially those with a peanut
allergy. Not only was epinephrine administration found to be lacking in the home, but it was also
found that delayed administration was also given in the hospital setting. In this study they
learned that only 53% of people prescribed an epinephrine autoinjector had it with them at the
time of the allergic reaction. They state that, ongoing efforts are needed to educate allergic
individuals and health care professionals about risks, avoidance, and management.
Cherkaoui et al. (2015) produced a quantitative longitudinal study that looked at a cohort
of Canadian children with a peanut allergy. In their sample of 1941 children 109 (28.9%) sought
medical attention, but only 40 (36.7%) children received epinephrine. They also state in their
literature review that their findings of low rates of epinephrine use is consistent with other
literature. They state that, more education is required on the importance of strict allergen
avoidance and the need for prompt and correct management of anaphylaxis.

PEANUT ALLERGY AND ANAPHYLAXIS IN CHILDREN

In a quantitative study by Liew et al. (2013) it was found that peanut anaphylaxis is the
top food trigger in Singaporean children. A survey they used found that epinephrine was
prescribed mainly to children <15 years old who had a peanut allergy and was at risk for
anaphylaxis. However, most of these children were not Singaporean children. Lastly, in a
qualitative, mixed methods study by Abdurrahman et al. (2013) it was discovered that there was
a lack of prescribing the epinephrine autoinjector and also a lack of education on how to properly
use the autoinjector and its settings.
Discussion/Implications
The findings of the integrative review address how patients with a peanut allergy
compared to those with any other food allergy are at greater risk for anaphylaxis between the
ages of 0-18. Therefore, the review findings relate to and support the researchers PICO question.
Three of the five articles, two quantitative and one both qualitative and quantitative, found that
peanuts were the leading cause of serious allergic reactions or anaphylaxis in children under 18
compared to other allergens such as other tree nuts, seafood, milk, tomato, beer, and MSG
(Abdurrahman et al., 2013; Liew et al., 2013; Xu et al., 2011). In the two other quantitative
articles the researchers speak to the high rates of occurrence of anaphylaxis in children who are
allergic to peanuts (Cherkaoui et al., 2015; Wainstein & Saad, 2015). However, in the literature
reviews of these two articles the researchers reference other studies that support the findings that
peanut is one of, if not the biggest cause of food related anaphylaxis.
The major themes of inadequate patient education and the lack or untimely use of the
epinephrine autoinjector is seen throughout all five articles. The articles definitely support the
need for improved patient education techniques among healthcare workers. Throughout the
articles a variety of different educational opportunities are mentioned such as educating in the

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PEANUT ALLERGY AND ANAPHYLAXIS IN CHILDREN

hospital, clinics, doctors offices, and even in the food service industry (Abdurrahman et al.,
2013; Cherkaoui et al., 2015; Liew et al., 2013; Wainstein & Saad, 2015; Xu et al., 2011).
Specifically, the lack of knowledge, use, and correct administration regarding the epinephrine
autoinjector is mentioned multiple times throughout the articles, in addition to the lack of
education regarding the peanut allergy in general. Educating patients is a large part of the nursing
profession. This is a great opportunity for nurses to increase positive patient outcomes in many
settings.
Limitations
There are multiple limitations that have affected the quality and content of this integrative
review. This review is the researchers first attempt at writing an integrative review, therefore
there is a significant lack of finesse, experience and knowledge affecting the quality of this
project. The researcher is also a full time student with limited time due to school, work and other
life commitments. This integrative review was limited to 5 articles completed within the past five
years. Another limitation is that two of the studies were based in Canada, one was based in
Australia, another in Singapore and only one was based in America. The vast geographic
differences make the information less applicable to the population in this country because only
one study was based in the United States. Lastly, the only person working on this review was the
researcher.
Conclusion
The overarching conclusion of this integrative review is that patients with a peanut
allergy compared to those with any other food allergy are at greater risk for anaphylaxis between
the ages of 0-18 years. Beneficial findings gathered from this review include the concept that
there is a significant need for more education regarding the peanut allergy in general and the lack

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PEANUT ALLERGY AND ANAPHYLAXIS IN CHILDREN

or untimely use of epinephrine. There is a growing body of literature regarding the seriousness of
peanut allergy in children, which is a welcome development considering the findings of this
integrative review. There is great opportunity to expand the patient teaching given in the hospital
and clinic settings and possibly even expanding education to the food service industry as well.
The role of educator is an integral part of the nursing profession, because of this, nurses are in a
great position to be the initiators of change in this area of healthcare.

References

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PEANUT ALLERGY AND ANAPHYLAXIS IN CHILDREN

Abdurranman, Z. B., Kastner, M., Wurman, C., Harada, L., Bantock, L., Cruickshank, H., &
Waserman, S. (2013). Experiencing a first food allergic reaction: a survey of parent and
caregiver perspectives. Allergy, Asthma and Clinical Immunology, 9(1), 18. Retrieved
from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3671211/
Cherkaoui, S., Ben-Shoshan, M., Alizadehfar, R., Asai, Y., Chan, E., Shand, G., St-Pierre, Y.,
Harada, L., Allen, M., & Clarke, A. (2015). Accidenal exposure to peanut in a large
cohort of Canadian children with peanut allergy. Clinical and Translational Allergy,
5(16), 89-94. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4389801/
Liew, W.K., Chiang, W.C., Goh, A.E., Lim, H.H., Chay, O.M., Chang, S., Tan, J.H., Shih, E., &
Kidon, M. (2013). Pediatric anaphylaxis in a Singaporean children cohort: changing food
allergy triggers over time. Asia Pacific Allergy, 3(1), 29-34. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3563018/
Wainstein, B. K., & Saad, R. A. (2015). Repeat oral food challenges in peanut and tree nut
allergic children with a history of mild/moderate reactions. Asia Pacific Allergy, 5(3),
170-176. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4521166/
Xu, Y.S., Kastner, M., Harada, L., Xu, A., Salter, J., & Waserman, S. (2011). Anaphylaxis-related
deaths in Ontario: a retrospective review of cases from 1986 to 2011. Allergy, Asthma
and Clinical Immunology, 8(Suppl 1), A8. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3487829/

NUR 4122: Nursing Research Evaluation Table

Appendix: Table 1
First
Author
(Year)

Concept
ual
Framew
ork

Design/
Method

Abdurrahma
n et al.
(2013)

No
conceptua
l
framewor
k was
identified

Mixed
methods
study
using
qualitativ
e and
quantitati
ve data.
Qualitativ
e analysis
was
guided by
grounded
theory
methodol
ogy

Sample/
Setting
Where
did they
get
them?
184
caregiver
s
participat
ed. 71%
were
from the
Canadian
province
of Ontario
and the
rest were
from
eight
other
provinces

Major
Variables
Studied
(and their
definition)

Measure
ment

Data
Analysis

Findings

Appraisal:
Worth to
practice

To better
understand
the
experience
s of
caregivers
of children
with a first
allergic
reaction to
food and to
identify any
deficiencies
in
information
received

Data was
coded from
transcripts
using
NVivo 9
software.
Two
investigato
rs
independe
ntly
developed
a coding
scheme to
help label
the
patterns in
the
identified
themes.
Online
surveys
and
qualitative
interviews.

Narrative
analysis
based on
Grounded
Theory,
Conceptu
al
Similaritie
s and
Themes.

This study
revealed
multiple
deficiencies
in the
distribution
of
information
to
caregivers
of children
with
allergies

This study
provides a
qualitative
view point
relating to
the lack of
patient
education
given to
caregivers
of children
with
allergies as
well as the
lack of
teaching
regarding
epinephrin
e
autoinjecto
rs.

Cherkaoui et
al. (2015)

No
conceptua
l
framewor
k was
identified

Quantitati
ve
Longitudin
al Cohort
study

Nonprobabilit
y
purposive
sampling
using
1941
patients

The annual
incidence
of
accidental
exposure ,
the
severity of
exposure,
manageme
nt, location
and
identified
associated
factors.

Survey tool

Statistical
analysis
was
complete
d using
Stata
version 13

Accidental
exposure to
peanuts in
allergic
children
continues
to occur
despite
increased
awareness.
This is due
to
inappropria
te patient
teaching
and
manageme
nt by
healthcare
professiona
ls

Liew et al.
(2012)

No
conceptua
l
framewor
k was
identified

Quantitati
ve
retrospect
ive study

98
Singapore
an
children
with a
history of
anaphyla
xis
between
the years
2005-

The
researchers
wanted to
retrospecti
vely study
the cases
of
anaphylaxi
s in
Singaporea
n children

Medical
records of
the
children
were used
to gather
data. The
skin prick
test (SPT)
was also
used on all

ChiSquare
analysis
or Fishers
exact
test. The
MannWhitney U
test or the
Students
t test

Food
anaphylaxis
in
Singapore
has
drastically
changed
overtime.
Peanut
allergy
used to be

This study
states that
more
education
is required
on the
importance
of allergen
avoidance.
It also
states the
need for
prompt
and
accurate
manageme
nt of
anaphylaxi
s through
the use of
epinephrin
e
One of the
researcher
s major
findings
was that
there is a
very low
public
awareness
of peanut
allergy and

Wainstein &
Saad, (2015)

No
conceptua
l
framewor
k was
identified

Quantitati
ve Cohort
Study

2009

between
the dates
of January
2005 and
December
2009

participant
s who
presented
with a
history of
food
allergy

Using
nonprobabilit
y
purposive
sampling,
26
children
who had
been
referred
from
Sydneys
Children
Hospital

The aim of
this study
was to
describe
any
changes in
the
reaction
severity or
threshold
dose in
children
with a
history of
peanut

Oral food
challenges
(OFC)

were used
for
compariso
ns
between
nonparametri
c and
parametri
c
variables.
Pvalues<0.
05 which
are
statisticall
y
significant
Categoric
al data
was
compared
using Chisquare
test and
continuou
s data
was
compared
using the
Student t
test for
parametri

almost
absent and
now it is
the top
food
trigger.

an extreme
lack of
labeling
and
regulation
which
leads to
increased
incidents of
anaphylaxi
s.

Most
childrens
peanut
allergy
worsened
overtime,
with two
children
experiencin
g
anaphylaxis
.

During the
course of
study the
researcher
s noticed a
lack of
documente
d patient
teaching in
the
patients
charts.
They also
noticed
that many

Xu et al.
(2011)

No
conceptua
l
framewor
k was
identified

Quantitati
ve and
qualitativ
e
retrospect
ive caseseries
analysis

Allergy
Clinic
participat
ed in this
study.

allergy.

92 deaths
related to
anaphyla
xis in the
past 26
years

Examine all
cases of
fatal
anaphylaxi
s in Ontario
to
determine
the cause
of death,
associated
features, co
factors,
and trends
in mortality

Ontario
Coroners
Database.
Cases were
identified
from the
coroners
reports
using the
following
terms:
allergic
reaction,
anaphylax
is,
adverse
drug
reaction,
insect

c data
and the
MannWhitney U
test for
nonparametri
c data. P
value was
<0.05
which was
statisticall
y
significant
Quantitati
ve data
was
analyzed
using
descriptiv
e
statistics,
frequency
analysis,
and the
chi-square
test for
continuou
s data
using
SPSS.
Qualitativ
e data

patients do
not carry
their
epinephrin
e auto
injectors
with them
or use
them
appropriate
ly.

Factors
associated
with fatal
anaphylaxis
included
delayed
epinephrine
administrati
on, asthma,
allergy to
peanut,
food
ingestion
outside of
the home,
and
teenagers
with food
allergy.

This study
showed
that
delayed
use of
epinephrin
e
administrat
ion is
associated
with
anaphylacti
c deaths
and it
stated that
increased
education
should be a
high

sting,
Animal/sn
ake bite

was
analyzed
using
content
analysis
of
grounded
theory
methodol
ogy

priority to
help
decrease
anaphylaxi
s in
children
and
teenagers.