Elderflower

Elderberry is the bottle people buy in May and open in July. These are the questions our naturopaths ask in store, and they're usually about honest expectations rather than dose.

A good fit if

• You're an adult and you'll start in the first day or two of symptoms, rather than waiting to see how it goes
• The pack names Sambucus nigra, says which plant part is in it, and gives a standardisation percentage
• You've read about the mixed evidence on this page and you're comfortable trying it anyway
• You want something for a short course in cold season, not a supplement to take all year

Check with us first if

• You're pregnant or breastfeeding. The Australian review found insufficient evidence for use in pregnancy or breastfeeding, and no trial here included a pregnant woman.
• You take prescription medicines. We couldn't find any published interaction study for elderberry, and the commonly repeated cautions have no verified source. Unknown isn't the same as safe.
• You have an autoimmune condition or take immunosuppressants. The common online warning that elderberry overstimulates the immune system isn't supported by the human evidence, and the 2021 systematic review found no sign of it. That isn't proof of safety either, so talk to your prescriber.
• You have diabetes, or you're watching your sugar. The syrup trials used 60 mL a day of a sweetened syrup, which is a real amount of sugar in a format often given to children.
• The person taking it is a teenager. The only elder guidance adopted by a regulator starts at 12, and the trial that gave over-13s four doses a day found no benefit.
• The person taking it is a child under 12. The one trial in 5 to 12 year olds found nothing, and European guidance excludes them.
• You take prescription medicines. Check with your doctor, pharmacist or our naturopaths before you start.

• Standardised membrane-filtered berry extract capsules, 22 per cent polyphenols and 15 per cent anthocyanins. Best known for: The only elderberry material with a defined chemical specification behind a published human trial. Absorption: Not established. No absorption study for elderberry anthocyanins could be found. Typical use: 600 mg a day to start, then 900 mg a day. This is the material behind the finding of fewer cold days in 312 Australian travellers, and that trial was funded by the extract's manufacturer.
• Elderberry syrup and liquid tonic. Best known for: The original clinical material, and still the format most people picture. Absorption: Not established. Typical use: The systematic review pooled three flu treatment studies with only 87 participants between them. That's a small base, and the syrup trials used commercial products.
• Liquid elderberry extract at 5.7 g per 15 mL dose. Best known for: The dose form used in the only large independent trial, which is also the one that failed. Absorption: Not established. Typical use: Nothing is supported here. Symptoms took 5.3 days to settle on elderberry against 4.9 on placebo, and the authors wrote that they found no evidence of benefit.
• Elder flower, as dried flowers or liquid extract. Best known for: A different part of the plant with the opposite regulatory story. It's the only elder material with an adopted European herbal monograph. Absorption: Not applicable. The monograph is based on traditional use, not trials. Typical use: Traditionally used to relieve early common cold symptoms, usually as a tea, in adults and teenagers over 12, with medical advice if symptoms last longer than a week.
• Gummies, lozenges and chewables. Best known for: The most common format in stores, especially for children, and the one nobody has tested. Absorption: Not established. Typical use: No trial we could find used a gummy or a lozenge. The dose and standardisation are usually left off the pack entirely.
• Whole dried berry, labelled as "dry berry equivalent". Best known for: An equivalent weight of dried fruit rather than an extract specification. Absorption: Not established. Typical use: "Equivalent to X mg of fresh fruit" can't be compared with a trial dose without the extract ratio and the anthocyanin figure. Treat it as a marketing number until the ratio is disclosed.
• American elder (Sambucus canadensis) and dwarf elder (Sambucus ebulus). Best known for: Different species, both legally allowed in Australian listed medicines. Absorption: Not established. Typical use: No clinical trial we could find used either, and we found no safety data for dwarf elder. Don't assume they behave like black elder.

Reference values. There isn't one, and there can't be. Elderberry is a plant, not a nutrient, so there's no recommended intake, no deficiency and no recommended daily amount. Any percentage of daily intake on an elderberry pack refers to something else added to it, usually vitamin C or zinc.

Typical supplemental range. This is where elderberry gets genuinely confusing, so we'll be plain about it. The trials used three units that can't be compared. The travel trial used 600 mg a day of an extract standardised to 22 per cent polyphenols and 15 per cent anthocyanins, rising to 900 mg a day around the flight. The syrup trials used 15 mL four times a day, so 60 mL in total. The negative trial used 5.7 g per 15 mL dose. Australian capsules are often labelled in dry berry equivalent milligrams instead, which measures something else again. A product can only be described as matching a trial dose if its label gives the standardisation figures, not just the equivalent weight.

Upper level. Australia's permitted ingredients list (Schedule 1) sets no daily dose cap for Sambucus nigra, Sambucus canadensis or Sambucus ebulus, and we couldn't find an upper limit in any source. That doesn't mean anything goes. A company still has to hold evidence for the dose it uses, and European guidance on elderflower limits it to adults and over-12s, and to short courses.

Worth knowing. Timing matters more than dose in every positive result here. The studies that found a benefit all started within roughly 48 hours of the first symptom, and the one that recruited people already sick enough for an emergency department is the one that found nothing. What you need depends on your age, diet and health, so talk to one of our naturopaths.

Food first, where the diet allows it.

• Cooked elderberries, as cordial, jam, syrup or wine: not quantified. No verified composition table for elderberry could be retrieved, so we won't publish a figure
• Raw elderberries: not a food. Raw fruit, and anything including leaves, stems or branches, carries a documented poisoning risk
• Elder flower: traditionally taken as a tea brewed from the dried flowers

If any of these sound like you, talk to one of our naturopaths or your doctor before you start.

• Raw or home-prepared elder. Never. Uncooked berries and any material from the leaves, stems, branches, buds, bark or roots can produce hydrocyanic acid (cyanide); in one documented outbreak 11 people fell ill and 8 went to hospital.
• Children under 5, where the product makes a fever or cooling claim. The Australian label must state: "Not to be used in children under 5 years."
• Children under 12. The only elder monograph adopted by a regulator limits use to adults and teenagers over 12, and the trial that gave it to 5-to-12-year-olds found no benefit.
• Pregnancy and breastfeeding. The Australian rapid review found the evidence insufficient, and no trial included pregnant women.
• Prescription medicines of any kind. No published study of elderberry interactions with medicines could be found, so the risk is unknown rather than absent.
• Autoimmune disease and immunosuppressant medicines. The worry about overstimulating the immune system isn't backed by human evidence, but that's not the same as being disproven.
• Diabetes and low-sugar diets. Syrups were given at 60 mL a day in trials.
• The side effects reported in trials were dry mouth, constipation and rash, with no significant difference from placebo.
• Sambucus ebulus (dwarf elder). It's allowed in Schedule 1 but is a different plant, and we found no safety data and no clinical trial for it.
• If you take prescription medicines, check with your doctor, pharmacist or our naturopaths before you start.