Elderberry

Early written references

A history of the plant published by the American Herbal Products Association describes black elder (Sambucus nigra) as a shrub or small tree typical of the north-central European landscape, found near farms, gardens and hedges. The article states that the plant was already used for gynecological conditions and dropsy in the corpus of writings ascribed to Hippocrates (5th-4th century BCE), and that Dioscorides' De materia medica (1st century CE) describes the root, leaves and fruit with several therapeutic uses. The passages it summarizes do not mention colds or influenza.

The same article reports that the range of uses grew over time, earning the plant the nickname 'medicine chest of country people'. It ties the phrase to this broadening of use and does not attribute it to Hippocrates, and the sources reviewed for this page do not support the popular statement that Hippocrates himself used that phrase. The article also records medieval and later folklore in which the elder became a plant of sorrow, and a belief, particularly in England, that elder leaves fixed to doors and windows kept out charms and spells.

Folk use for colds and influenza

A 2004 trial report states that elderberry has been used in folk medicine for centuries to treat influenza, colds and sinusitis. A 2021 systematic review similarly describes traditional use for respiratory problems, and a 2022 review states that in traditional medicine dried fruit or flowers were used for respiratory problems such as influenza or colds. These are general statements. The sources reviewed do not trace folk use against colds to a specific region, period or text.

Modern standardized extracts

A 1995 report by Zakay-Rones and colleagues described a standardized elderberry extract called Sambucol, which inhibited replication of several human and animal influenza virus strains in cultured canine kidney cells. The same report described a placebo-controlled, double-blind study in a kibbutz community during a 1993 influenza B outbreak. That study and a 2004 Norwegian trial by an overlapping group of authors are among the trials in the sources reviewed.

Names and plant parts

The American Herbal Products Association history uses the names Black Elder and Sambucus nigra L., family Adoxaceae, and says the English word elder comes from the Anglo-Saxon aeld, meaning fire, a naming it says is believed to come from the use of hollowed branches as blowpipes. Trial and review reports in the sources use the terms elderberry extract, elderberry syrup and black elderberry (Sambucus nigra) supplementation, and a 2014 Natural Standard systematic review covers elderberry and elderflower together. This page uses Elderberry for preparations of the berries and flowers of Sambucus nigra.

Species and product names

A 1984 public health report on a juice poisoning concerned Sambucus mexicana, the indigenous elder of the western United States, and its editorial note mentioned older anecdotal poisoning reports from the related Sambucus canadensis. Sambucol, named in the 1995 report, is a brand of standardized extract. Trials in the sources used different products, for example a syrup in the Norwegian trial and a membrane-filtered extract in the air-travel trial, so a finding for one preparation should not be assumed to apply to another species or product.

Forms of elderberry products

The sources describe elderberry as an oral syrup in the 2004 trial, as a standardized extract in the 1995 and 2016 trials, and as an over-the-counter supplement in a 2024 case report. The National Center for Complementary and Integrative Health (NCCIH) notes that elderberry products are often sold as dietary supplements, which are not approved by the U.S. Food and Drug Administration before sale. The sources reviewed do not describe gummies or other consumer formats separately, so findings from syrups and extracts should not be assumed to apply to them. This page gives no doses, recipes or preparation instructions.

Place within Machipedia

Elderberry is one of the plant remedies in the family covered by the Machipedia page Herbal Medicine, which should be read for the general overview of plant-based practices. Related Machipedia pages include Echinacea, another herbal remedy, and Dietary Supplements, as well as Naturopathy and Homeopathy. These are separate pages, and this entry does not describe their content or assess whether practitioners in those fields use elderberry.

Colds and influenza

The sources describe elderberry studied and marketed to ease or shorten colds, influenza and other upper respiratory infections. The 2004 trial authors framed it as a possible treatment for influenza A and B, the 2016 trial examined cold episodes in air travelers, and the 2021 systematic review also looked at prevention of viral respiratory illness. A 2019 meta-analysis framed elderberry as an alternative for upper respiratory symptoms. NCCIH states that a few studies have looked at elderberry for colds, flu and other upper respiratory infections.

Immune support and COVID-19

A 2024 case report states that elderberry flower extract is marketed as a supplement with purported benefits in boosting the immune system, and that its use increased during the coronavirus pandemic. NCCIH states that there is not good evidence for elderberry against COVID-19 and not enough information to show benefit for other health purposes. The 2021 systematic review notes that no included study involved people with COVID-19, and a 2022 review concludes that further research is required for COVID-19 patients.

Influenza trials

The 2004 trial enrolled 60 adults aged 18 to 54 with influenza-like symptoms of 48 hours or less during the 1999-2000 influenza season in Norway. It was randomized, double-blind and placebo-controlled. The authors reported that symptoms were relieved on average 4 days earlier in the elderberry group and that rescue medication use was lower, and they called for confirmation in a larger study. The earlier 1995 report described a kibbutz study during an influenza B outbreak in which the treated group reported faster symptom improvement, alongside laboratory findings in cell cultures.

The 2021 systematic review states that elderberry may reduce the duration of influenza but that the evidence is uncertain. It also reports that, compared with oseltamivir, an elderberry-containing product may be associated with a lower risk of influenza complications and adverse events, again with uncertain evidence.

Colds and the air-travel trial

The 2016 trial randomized 312 economy-class passengers flying from Australia to an overseas destination to a standardized elderberry extract or placebo. Cold episodes were more frequent in the placebo group (17 versus 12), but the difference was not significant (p = 0.4). Total cold days were 117 in the placebo group and 57 in the elderberry group (p = 0.02), and average symptom scores were higher in the placebo group (p = 0.05). The 2021 review states that elderberry may not reduce the risk of developing the common cold and may reduce its duration and severity, with uncertain evidence.

Reviews and meta-analyses

A 2019 meta-analysis of randomized controlled trials, covering 180 participants in total, reported a large mean effect size for reduced upper respiratory symptoms. The 2021 systematic review screened 1,187 records, included five randomized trials, assessed risk of bias with Cochrane tools and rated certainty with GRADE. It reported trial sizes of 27 to 420 participants and described the evidence on both benefits and harms as uncertain. The two reviews differ in how strongly they characterize the findings, and the sources do not reconcile that difference.

A 2014 Natural Standard systematic review also graded safety and efficacy data for elderberry and elderflower. The searches run for this page were limited to PubMed and the sources listed here, and they did not identify a Cochrane Library review specific to elderberry.

The cytokine-storm concern

During the COVID-19 pandemic, concern was raised that elderberry might overstimulate the immune system and increase the risk of a cytokine storm. The 2021 systematic review found no studies linking elderberry to clinical inflammatory outcomes and three studies measuring cytokines ex vivo, with some effect on inflammatory markers that may decline with ongoing supplementation. It concluded that there was no evidence of overstimulation, while stating the evidence was uncertain. A 2022 review states that there is not yet enough evidence to support the concern and that further research is needed for COVID-19 patients. The concern remains hypothetical.

Raw berries, leaves, bark and stems

NCCIH states that raw or unripe elderberries and the leaves and stems of the elder tree contain cyanide-producing substances, that cooking destroys this toxin, and that effects can include nausea, vomiting and severe diarrhea. A 1984 report described an outbreak after a gathering in Monterey County, California, in August 1983: 11 people developed nausea and vomiting within 15 minutes of drinking juice made from wild elderberries crushed with their leaves and branches, and the eight most ill had abdominal cramps and weakness. Serum cyanide levels were normal, all recovered, and severity correlated with the amount of juice consumed.

The report's editorial note states that the fresh leaves, flowers, bark, young buds and roots of the plant contain a glucoside that under certain conditions can produce hydrocyanic acid, with the root probably the most poisonous part. The sources reviewed give no preparation instructions for this page, and readers should treat home preparation from wild plants as a poisoning risk documented in these sources.

Medicines, medical conditions and pregnancy

NCCIH advises checking with a health care provider before using elderberry when taking any medicine, and states that little is known about use during pregnancy or breastfeeding. A 2024 case report described a woman who took over-the-counter elderberry supplements and developed grade 3 liver injury on pazopanib, a cancer drug; liver enzymes normalized after all medicines were stopped. The authors proposed an interaction through the CYP3A4 enzyme pathway, but a single case cannot establish cause.

The 2021 systematic review reported no serious adverse events in the included studies, but it described adverse-event reporting as limited and the certainty of harms evidence as low to very low. It notes that no included study involved people with inflammatory conditions. The sources reviewed give no specific guidance for autoimmune conditions or immunosuppression, so people in those groups, and people who are pregnant or breastfeeding, are among those for whom clinician advice is relevant.

Quality, labeling and care boundaries

NCCIH states that manufacturers are responsible for evaluating the safety and labeling of dietary supplements, so product quality can vary. A 2022 review of label compliance lists elderberry among top-selling botanical ingredients marketed for immune health that are subject to adulteration and inaccurate labeling, partly linked to pandemic supply-chain issues. Influenza and other respiratory infections can need medical assessment, and elderberry should not be used to replace or delay necessary care.