Nuts!

You may recall that one of our major challenges with this diet is that keto diets typically make use of a lot of nut-based foods - milk substitutes, flours, butters, and the nuts themselves as snacks - so since M was diagnosed with allergies to all nuts after a reaction to peanut butter when he was six months old, we've had some frustrations.

A funny thing happened, though - once we made the decision to try keto for M, we spent a lot of time scouting out what we thought would be keto-friendly toddler snacks at Trader Joe's and other grocery stores. My husband found some kale chips that were fairly high in fat and had some of the good kale vitamins and minerals and he tried them out on M, who seemed to love them. What a win!

It was a few days later when I looked carefully at the packaging and noticed the giant words "... IN CASHEW BUTTER".

So our allegedly nut-allergic son had been eating kale chips covered in cashew butter for a week and he was not reacting. Huh. (And holy crap, did we get lucky.)

We went back to our allergist (who we didn't particularly like after our first encounter, but you go to war with the army you have, I guess) and asked for a short-notice appointment to re-test M. We told him we were starting keto as a medical treatment and wanted to include some nuts if we could, and told him it appeared he could tolerate cashew, so could we re-test? To their credit, they did get us a short notice appointment, but they only re-did the skin test for a few nuts, declared M still reactive to everything, and told us not to give him any more cashew as "it will make it worse."

So we trundled along for months with no nuts until I mentioned my frustrations to our lovely dietician, who pointed us to an allergist at the same hospital she'd recently heard a talk from, and he had a reputation for being a little more aggressive about food allergies than most allergists. I started doing some reading, trying to find the work he'd published, and in the process learned a lot.

Like, the fact that skin tests and blood tests can only *confirm* an allergy after an oral reaction; they can't diagnose them. The only way to be sure is to do an oral challenge - that is, feed someone the thing they might be allergic to, and see if they react, with Epi-pens at the ready. I also discovered that the IgE readings - the measurement of the antibodies produced in your blood when you have an allergic reaction - have a whole range, and within a certain lower range there's at least a 50/50 chance of successfully passing an oral challenge. I also learned about the low IgE readings that indicate there's probably no reactivity, it's just the error band of the test.

When I went back to review M's original results, it looked a lot like there were some nuts that fell into those latter two bands, including cashew. And it also meant that the skin tests that the allergist had re-run were totally meaningless.

So we got an appointment with the new allergist, even though it was a couple of months out, and waited patiently. The big day finally arrived and he ran the blood and skin tests again for a full panel of all tree nuts. The result: he is most definitely severely allergic to pecans, peanuts, and walnuts. He seems to be moderately allergic to almond and hazelnuts, and may grow out of those some day. But he had very low readings on pistachio and cashew, and no reaction at all to macadamia and Brazil nuts.

Well THIS was life-changing! We told the allergist we wanted to move ahead with oral challenges on those last four, and prioritized them: first macadamia nuts, since they're so high in fat. Then Brazil nuts, since they're commonly recommended as a snack in medical keto diets due to their high selenium content - an important mineral people on therapeutic keto can become dangerously deficient in. Then cashew and pistachio, the more risky ones, which fortunately are cross-reactive so if he passes the cashew challenge, he should be fine with the pistachios too.

We've already done macadamia and Brazil nut. In both cases, since they had near-zero reactivity in the skin and blood tests, we were allowed to do them in the hospital's standard Saturday morning allergy clinic in just two hours. I made him snacks with small amounts of each nut and let him nibble on it while we waited to see if any immediate or longer-term reactions would occur, and the allergist checked in with us every 20-30 minutes to check his respiration and skin. Both those appointments went smoothly, and we're already making good use of the new additions to his diet.

Cashew, the next one, will be a little more of an ordeal. Since he did have *some* blood reactivity, there is a risk he will have a real reaction, so that challenge will be done in a higher-touch setting in the hospital. They'll have nurses on hand the entire time and he'll be given increasing amounts of cashew butter over the course of 3-4 hours, closely monitored throughout. But if he passes that one, that's two more we can add on - and I've already got my eye on this pistachio rosewater muffin recipe.

So there we go - a few nuts are back on the menu and a whole bunch of recipes - especially those baked goods - have just gotten a million times easier to adapt!

I will try to provide nut-free recipes whenever possible, since I still think there's too few of those out there for the folks that really need them. But if you start seeing some nuts show up in my recipes, that's why!