State-of-the-Art Pediatrics

Elderberry – Is the Herbal Remedy Safe for Kids?

Co-author: Emily J. Goodwin, MD, FAAP | Pediatrician | Clinical Assistant Professor of Pediatrics, UMKC School of Medicine; University of Kansas School of Medicine

Co-author: Alannah Yoder, PharmD, BCACP | Clinical Pharmacy Specialist | Adjunct Clinical Assistant Professor, UMKC School of Pharmacy

Column Editor: Amita R. Amonker, MD, FAAP | Pediatric Hospitalist | Assistant Professor of Pediatrics, UMKC School of Medicine 

It is the time of year when we see many families using elderberry in the hopes it will help their child stay well and to ward off infection. Natural products, including elderberry, are becoming increasingly popular. They have been marketed to prevent and treat common colds or influenza, or most recently even COVID-19. This trend prompts us to ask: are the claims valid and is it safe?

What is elderberry?

Elderberry, Sambucus nigra, is the dark purple berry of the Europea­­n or Black Elder tree. It grows in Europe, Africa, Asia, and North America, including the midwestern United States.¹ In addition to patients purchasing commercially available products, some may also be making their own or purchasing other homemade formulations. The concept of elderberry is not new; it has been used for many years in folk medicine to treat colds and influenza.² However, elderberry is now found in many forms including syrups, capsules and gummies. It also may be added to other over-the-counter (OTC) products such as cough syrups and multivitamins.

Are the claims valid?

Initial claims for elderberry in the treatment of influenza stemmed from a few small clinical trials.^3,4 One of these showed elderberry extract shortened the duration of influenza-like symptoms by four days.⁴ However, these studies included adult patients and concluded additional trials were needed, making it difficult to make evidence-based recommendations in children. Recently, a trial evaluating use in pediatric patients was published. The study evaluated patients older than 4 years old with a positive influenza test and <48 hours of symptoms. Elderberry was not found to have a benefit on duration or severity of influenza symptoms.⁵ There is no evidence to support using elderberry for the prevention or treatment of COVID-19, and the U.S. Food and Drug Administration has issued warning letters for fraudulent products.⁶

Is the home remedy safe?

There have been many safety concerns surrounding the use of elderberry. Unripe or uncooked parts of the elder tree (including leaves, stems and berries) can be dangerous if ingested as they contain toxins such as sambunigrin, a cyanogenic glycoside.^1,2 The toxins can lead to nausea, vomiting, diarrhea and more serious consequences if ingested in large quantities. While cooking eliminates the toxin, it may be difficult to know if this is done appropriately when made at home or using other non-regulated homemade products. Commercial products purchased from the store may also be a concern. Many of these products contain additional ingredients such as echinacea. Echinacea may impact the metabolism of cytochrome p-450 enzymes, including CYP3A4 and CYP1A2, leading to potential drug interactions. Elderberry should not be used in patients with autoimmune diseases and/or taking immunosuppressant medications.²

How can we help?

1. Inform patients and families that these products have not been shown to prevent or treat infection and may be dangerous. Encourage families to discuss elderberry and all herbal products and supplements with their health care team before using. Additional family-friendly information about elderberry may be found here: https://www.childrensmercy.org/parent-ish/2021/01/elderberry/.
2. Provide evidence-based recommendations for infection prevention. Parents are giving elderberry or other products to try to keep their child healthy. It is important to provide education in a patient-centered manner about what is known and where more research is needed. Encourage evidence-based recommendations to prevent common infections. The measures we have been encouraging throughout the pandemic, including handwashing, wearing masks, social distancing and routine immunizations, have been demonstrated to prevent infections and reduce risk of complications.⁷ Influenza vaccination is recommended for all children over 6 months old and a COVID-19 vaccine is not yet available for children under age 16 years.  

References:

1. Elderberry. National Center for Complementary and Integrative Medicine. Updated August 2020. https://www.nccih.nih.gov/health/elderberry.
2. Elderberry. Natural Medicines. Updated Dec. 16, 2020. http://naturalmedicines.therapeuticresearch.com [Database subscription].
3. Zakay-Rones Z, Varsano N, Zlotnik M, Manor O, Regev L, Schlesinger M, et al. Inhibition of Several Strains of Influenza Virus in Vitro and Reduction of Symptoms by an Elderberry Extract (Sambucus nigra L.) During an Outbreak of Influenza B Panama. J Altern Complement Med. 1995; 1 (4): 361-9. 
4. Zakay-Rones Z, Thom E, Wollan T Wadstein J. Randomized Study of the Efficacy and Safety of Oral Elderberry Extract in the Treatment of Influenza A and B Virus Infections. J Int Med Res. 2004; 32 (2): 132-40. 
5. Macknin M, Wolski K, Negrey J Mace S. Elderberry Extract Outpatient Influenza Treatment for Emergency Room Patients Ages 5 and Above: A Randomized, Double-Blind, Placebo-Controlled Trial. J Gen Intern Med. 2020; 35 (11): 3271-3277.
6. Fraudulent Coronavirus Disease 2019 (COVID-19) Products. U.S. Food and Drug Administration. Updated Jan. 6, 2021. https://www.fda.gov/consumers/health-fraud-scams/fraudulent-coronavirus-disease-2019-covid-19-products.
7. Recommendations for Prevention and Control of Influenza in Children, 2020–2021. Committee on Infectious Diseases. Pediatrics Oct 2020, 146 (4) e2020024588.