IgE-Mediated Legume Allergy in Children: Insights from a Single-Center Experience in Italy.

Background/Objectives: Legume allergy is increasingly recognized as plant-based diets expand and legume proteins are widely used in processed foods. We aimed to characterize the clinical features, sensitization profiles, and management outcomes of IgE-mediated legume allergy in Italian children. Methods: This retrospective single-center study (January 2022-January 2024) included children (<18 years) allergic to ≥1 index legume (pea, lentil, chickpea, common bean, or soy). Diagnosis required a compatible clinical history and evidence of IgE sensitization. Clinical and allergy characteristics were analyzed. Results: Fifty-five children (63.6% male) were included; all had atopic comorbidities, and 96.4% had additional food allergies. Median age at first reaction was 18 months; anaphylaxis occurred at onset in 12.7%, most frequently triggered by pea. Pea (70.9%) and lentil (69.1%) were the most prevalent allergies, with pea causing 50% of index-legume anaphylaxis. Multi-legume allergy predominated (74.5%), with frequent co-allergy among pea, lentil, and chickpea (56-86%). Soy allergy was less frequent and mainly associated with Gly m 4 sensitization. Single-legume allergy (25.5%) was associated with later onset (54 vs. 15 months; p = 0.013) and liver transplantation (21% vs. 2%; p = 0.047). Peanut co-allergy occurred in 25.5%. Among 34 oral food challenges (OFCs), 23.5% were positive, including one case of pea-induced anaphylaxis. Of 16 oral immunotherapy (OIT) protocols initiated, 31.3% reached the full target maintenance dose, 37.5% remained on a lower, partial maintenance dose, and 31.3% were discontinued due to oral allergy syndrome (OAS). Conclusions: Pediatric legume allergy is characterized by early onset, frequent multi-legume involvement, and common co-allergies. In this cohort, pea allergy was associated with the highest proportion of severe reactions. Species-specific differences in severity, patterns of multi-legume involvement, and OIT outcomes should be interpreted cautiously given the limited sample size, while highlighting the need for tailored management and improved risk assessment across legume species.