New study expands list of foods that cause anaphylaxis

An analysis of nearly 3,000 episodes of food anaphylaxis (Ring 2-4) registered by the French Allergy-Vigilance Network from 2002 to 2023 was published in Clinical & Experimental Allergy. The researchers selected allergens that caused ≥1% of cases and are not included in the current European list of 14 food allergens that must be labeled. There were eight of these: goat and sheep milk (2.8% of cases), buckwheat (2.4%), peas and lentils (1.8%), alpha-gal (1.7%), pine nuts (1.6%), kiwi (1.5%), bee products (1.0%) and apple (1.0%). In total, these eight “hidden” allergens accounted for 413 episodes, including two fatal outcomes. Given the frequency, severity, tendency to relapse and risk of “hidden presence” in the composition, the authors propose to include four items - goat/sheep milk, buckwheat, peas-lentils and pine nuts - in mandatory labelling in the EU.

Background of the study

For over ten years now, the EU has had a single list of 14 allergens that the manufacturer must clearly highlight on the label and in the menu (Regulation No. 1169/2011, Appendix II). These are the "big classics": gluten grains, eggs, fish, milk (in general), peanuts, soy, "wood" nuts, celery, mustard, sesame, shellfish, etc. But the list is historical and does not cover the entire spectrum of allergens that consumers actually encounter in the modern grocery basket. This is why the issue of updating the list periodically arises - taking into account new food trends, imported cuisines and emerging vulnerabilities.

In recent years, the share of "plant proteins" and gluten-free alternatives in the European diet has increased significantly - hence the increasing use of peas, lentils and buckwheat in ready meals, snacks and "plant-based meats". According to reviews, allergies to legumes (including peas/lentils) are often fueled by cross-reactivity between homologous proteins of different legumes and can manifest as systemic reactions; buckwheat has been described as causing both anaphylaxis and occupational sensitization (for example, in catering workers). That is, these are not only "niches" of East Asian or Mediterranean cuisine, but increasingly mass-produced ingredients in Europe.

Another "grey area" is goat and sheep milk: formally, "milk" is already on the EU list, but in consumer practice, goat/sheep milk products are sometimes perceived as a "gentle" alternative for cow's milk allergies. Meanwhile, the proteins of these types of milk have a high homology with the proteins of cow's milk, and cross-reactivity in cow's milk allergy sufferers is very common - hence the risk of severe reactions to "alternative" cheeses and yoghurts. "Hidden" sources of severe reactions also include pine nuts (often in pesto/baked goods) and fruits such as kiwi (including due to the association with birch pollen in the "pollen-food" syndrome), and in some patients the reactions go far beyond the "oral syndrome".

A separate, “atypical” for labeling story is alpha-gal syndrome: delayed (after 3-6 hours) systemic reactions to mammalian products (red meat, sometimes dairy/gelatin), occurring after tick bites. The diagnosis is often missed, because the time delay “unbinds” the reaction from food in the eyes of the patient and doctor. Given the expansion of tick habitats and the growth of recognition of the diagnosis, the share of such cases in Europe and the USA is increasing - and they are almost never “highlighted” on the label.

Finally, the general context of the risk: anaphylaxis is more common in the population than is commonly believed, and estimates vary greatly between countries and registries (in Europe, from a few to tens of cases per 100,000 people per year). Two things are critical for prevention: (1) clear lists of allergens on packaging/in the menu that correspond to the real culprits of severe reactions; (2) competent organization of food in schools, hospitals and catering establishments, where “hidden” ingredients (flour mixtures, sauces, “plant-based meat”) are especially common. It is this “gap” between real episodes and formal lists that the labeling update is intended to close.

Why is this important right now?

Current EU regulations require 14 allergens to be explicitly listed (gluten-containing cereals, crustaceans, eggs, fish, peanuts, soy, milk, nuts, celery, mustard, sesame, sulphur dioxide/sulphites, lupine, shellfish). But the consumer basket is changing: the share of “plant” proteins (pea/lentil), ethnic products (buckwheat, soba noodles), sauces and spreads (pine nut pesto), and “new” sensitisation mechanisms such as alpha-gal syndrome after tick bites (delayed anaphylaxis to a mammalian protein) is growing. A new analysis shows that there are real common culprits of severe reactions outside the “classic 14” – and labelling policy must catch up with reality.

How severe were the reactions?

The authors assessed the degree according to the Ring-Messmer scale. Severe (Grade 3) and extremely severe (Grade 4) reactions were observed:

• with goat/sheep milk - Grade 3 in 46.8%, Grade 4 in 4.8% (both fatal cases also belong here);
• for buckwheat - 46.5% and 1.4%;
• for peas and lentils - 20% and 1.8%;
• with alpha-gal - 54% and 8%;
• pine nuts - Grade 3 in 49%, kiwi - 54.5%, bee products - 33.3%, apple - 46.7% (for these four, the share of Grade 4 is not highlighted in the annotation, but Grade 3 already refers to "life-threatening"). These are exactly the levels of severity that require adrenaline and emergency care in clinical guidelines.

The Eight 'New Common Culprits' - What Are These Products and Where Are They Hiding?

• Goat and sheep milk. Often found in cheeses, pastries, desserts; cross-reactivity in some patients with cow's milk allergy is unpredictable. High recurrence (56%) and latent presence (15.5%) in products.
• Buckwheat. Crackers, pancakes, Asian soba noodles, gluten-free mixes. Relapse rate 49.3%, “stealthiness” 16.9%.
• Peas and lentils. Proteins in "plant meat", protein bars, soups/purees. Relapses 7.3%, "secrecy" 9.0%.
• Alpha-gal. Unique case: sensitization after tick bites, reactions to red meat/mammal products 3-6 hours after eating (delayed anaphylaxis). Often underestimated and disguised as "idiopathic" cases.
• Pine nuts. Pesto, salads, baked goods; unlike the "wood" nuts from the "14", pine nuts are not singled out separately. Relapses 12.2%, latent exposure 4.1%.
• Kiwi and apple. In some patients, they manifest as systemic reactions, and not just "oral allergy syndrome" (crossover with birch). In the sample, the proportion of Grade 3 was high (54.5% and 46.7%).
• Beekeeping products. Propolis, royal jelly and other additives are often present in dietary supplements and "functional" products.

What the authors propose and what regulators should look at now

Based on four criteria - frequency, severity, recurrence, risk of lurking presence - the team recommends that goat/sheep milk, buckwheat, peas/lentils and pine nuts be considered as a priority for the EU list. This does not replace the "other four", but makes the update of the register phased and tied to the greatest risk. The publisher's press release also highlights: in a series of almost 3,000 anaphylaxis, 413 were due to these eight allergens, and there were two deaths - another argument for revising the rules.

Context: How current labeling works and where the gap is

Today, Regulation 1169/2011 is in force in the EU, and the list of 14 allergens from its Annex II must be highlighted in the composition (font/style) on the packaging and in the information for unpackaged dishes (restaurants, cafes). This list historically covers the "big players", but is not exhaustive - as demonstrated by the French chain. Updating the list is a matter of safety and transparency: the more inaccuracies between the real risks and the "contains" label, the higher the chance of accidental contact for allergy sufferers.

What this means "here and now" - for people with allergies, businesses and schools/canteens

For buyers and parents:

• Read the ingredients and ask about them in cafes - especially if you are allergic to milk proteins, legumes, nuts or birch pollen (for kiwi/apple).
• Beware of "hidden" sources:
  • buckwheat - in pancake mixes, gluten-free baked goods and Asian noodles;
  • peas/lentils - in "vegan meat", cutlets, pastas and protein snacks;
  • pine nuts - in pesto, salads, baked goods;
  • goat/sheep milk - in cheeses, yogurts, baked goods.
• If you have a history of severe reactions, carry an adrenaline autoinjector and follow the plan: “recognized - injection - call an ambulance - control.”

Restaurant and school meals:

• Double-check the recipes: some dishes may contain buckwheat/legumes/pine nuts or goat/sheep milk “by default”.
• Train staff: how to answer questions about allergens and what to do if anaphylaxis is suspected (adrenaline, algorithm).
• Voluntary transparency: Until the EU rules are updated, it makes sense to voluntarily list these eight allergens on menus/processing sheets - "when available".

For manufacturers and retailers:

• Supply chain audit: traces of buckwheat, legumes, pine nuts, bee products.
• Honest communication: Explain up front on websites and packaging (Q&A section) where and why an ingredient might appear.
• Ready for regulatory update: Annex II revision is a real scenario; better to be the first to “relabel” for safety.

Scientific and practical nuances

This study is based on an observational registry; it does not measure the true prevalence of allergy in the population, but records severe clinical episodes. However, the high proportion of Grade 3-4, relapses and latent exposure to a number of allergens are strong arguments for regulators. Alpha-gal syndrome deserves special attention: it often occurs with a delay after eating (hours), is associated with tick bites and requires specific screening to stop being disguised as “idiopathic” anaphylaxis. The next step is harmonization of labeling and educational campaigns for the catering industry and consumers.

Study source: Sabouraud-Leclerc D. et al. Food Anaphylaxis: Eight Food Allergens Without Mandatory Labelling Highlighted by the French Allergy-Vigilance Network. Clinical & Experimental Allergy, online 20 August 2025. https://doi.org/10.1111/cea.70130