CAFETERIA: Expanding Treatment Pathways for High-Threshold Peanut Allergy, with Scott Sicherer, MD

One year after the readout of the CAFETERIA trial, its implications for peanut allergy management continue to ripple through pediatric allergy practice. The NIH-sponsored study, published in NEJM Evidence, demonstrated that gradually increasing, home-measured doses of store-bought peanut butter over approximately 18 months enabled 100% of participating children with high-threshold peanut allergy to tolerate 9 grams of peanut protein, or the equivalent of 3 tablespoons of peanut butter, during supervised challenge.1 Even more striking, more than 2/3 achieved sustained unresponsiveness after a period of avoidance. For a population historically told that strict avoidance was their only option, the findings marked a meaningful shift.

Scott H. Sicherer, MD, Director of the Elliot and Roslyn Jaffe Food Allergy Institute and the Elliot and Roslyn Jaffe Professor of Pediatric Allergy and Immunology at the Icahn School of Medicine at Mount Sinai, gave a talk at the American Academy of Allergy, Asthma & Immunology (AAAAI) 2026 Annual Meeting held in Philadelphia, Pennsylvania, on February 27-March 2, discussing the data and takeaways from the CAFETERIA study.

HCPLive sat down with Sicherer at the meeting, who co-led the trial at the Elliot and Roslyn Jaffe Food Allergy Institute at Mount Sinai, to learn more about CAFETERIA and its importance in addressing a long-overlooked gap in peanut allergy. Prior peanut immunotherapy trials focused primarily on children reactive to trace amounts, or those unable to tolerate even half a peanut. But roughly half of peanut-allergic children can already tolerate more than that threshold. For them, the question had long been: if they are already relatively protected against trace exposures, should clinicians simply advise continued avoidance?

Historically, the answer was yes. Children who reacted mildly at modest doses during an oral food challenge were typically labeled “still allergic” and sent home with instructions to avoid peanut entirely. CAFETERIA challenges that reflex. Sicherer noted that children with higher thresholds, often with lower peanut-specific IgE levels, proved highly responsive to a structured, low-cost oral immunotherapy approach using everyday products measured at home. The safety profile was favorable, and the success rate was high.

One year later, Sicherer says the study has reshaped his clinical thinking. Instead of defaulting to annual reassessment and continued avoidance, clinicians can now view high-threshold peanut allergy as a treatment opportunity.

“For those individuals who typically have lower IG levels, who might be ones that you'd want to do a feeding test for a food challenge, or discovering that they …don't react to the smallest amounts, is really a pathway, an opportunity to try to treat them. And so that's changed the thinking for us, and I hope for everyone,” Sicherer said.

References

1. Sicherer SH, Bunyavanich S, Berin MC, et al. Peanut Oral Immunotherapy in Children with High-Threshold Peanut Allergy. NEJM Evidence. Published online February 10, 2025. doi: 10.1056/evidoa2400306

2. Sicherer S. FAED Presents: The Potential for Tolerance After Oral Immunotherapy in High-Threshold Patients: The CAFETERIA Study. Presented at: AAAAI 2026 Annual Meeting, February 27-March 2, Philadelphia, Pennsylvania. Session 1705.

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