Elderberry (Sambucus nigra, Holunder, Sureau)
The hedgerow medicine chest, now a hundred-million-dollar syrup
Evidence grade 2 of 5, Thin. Read how the Atlas grades evidence.
Zakay-Rones ran two small influenza trials, 27 patients in Israel in 1995 and 60 in Norway in 2004, both reporting symptoms relieved about four days earlier. Tiralongo's 2016 trial in 312 Australian air travellers reported shorter, milder colds using a manufacturer-supplied extract. Hawkins pooled four trials in 2019 and found reduced symptom duration. Macknin's 2020 emergency-room trial then found no influenza benefit, with a post hoc signal that elderberry alone did two days worse than placebo. Wieland's 2021 review of five trials, roughly 624 participants, found duration about two days shorter for colds and nearly three for influenza, and rated the certainty low to very low, citing dropouts, selective reporting and sponsorship.
Reference only. Not medical advice.
What can go wrong
Raw or unripe berries and the leaves, stems, bark and roots contain cyanogenic glycosides, and NCCIH warns they can cause nausea, vomiting and severe diarrhoea, with cooking removing the problem. The most-cited incident is from Monterey County, California in August 1983, where 25 people drank juice pressed from uncooked Sambucus mexicana berries together with leaves and stems and eight became ill enough to be flown to hospital, one of them stuporous. The chemistry is more complicated than the folklore. Berries and leaves of S. nigra ssp. canadensis have been shown to lack cyanogenic glycosides, commercial S. nigra juice has tested clean, and a 2021 reanalysis argues the 1983 episode was not cyanide poisoning. Red elderberry, S. racemosa, has genuinely poisonous seeds. Cook the fruit, discard the greenery, and do not free-pour a wild press. Adulteration is the other live hazard.
The black elder grows as a scruffy hedgerow tree across Europe, and both its cream-coloured flower heads and its small purple-black fruit have been used medicinally for as long as there are records. The berries are cooked into syrup, cordial, wine and jam, since raw they are unpleasant and mildly toxic. Modern interest concentrates on one claim, that a syrup taken at the first sign of a cold or flu shortens the illness. The berries are rich in anthocyanins, chiefly cyanidin-3-O-sambubioside, the marker compound laboratories use to tell real elderberry from cheaper substitutes. Several small randomised trials support the duration claim, most conducted with commercial products and several sponsored by their manufacturers. The largest independent trial, run in American emergency rooms, found nothing. The 2021 systematic review that pooled this literature rated its certainty low to very low, which is the fairest description available of where elderberry stands.
Cooked black elder fruit taken for colds and flu; small trials suggest shorter symptoms, the largest independent trial found none, and raw berries and leaves cause real poisoning.
How it is supposed to work
Elder anthocyanins and their flavonoid partners bind influenza virions in cell culture and appear to interfere with entry into host cells, which is where the antiviral story begins. Lectins and polyphenols also modulate cytokine release in vitro. What has not been shown is that any of this survives digestion at the doses people swallow, since anthocyanin bioavailability is famously poor. The gap between a virion assay and a shorter cold is exactly the gap the clinical trials were meant to close, and they have not closed it convincingly.
What people get wrong
Often saidElderberry syrup cuts the flu short by four days.
ActuallyThat number comes from two small trials of one branded syrup, 27 patients in 1995 and 60 in 2004. The larger 2020 emergency-room trial found no benefit at all, and its post hoc analysis suggested elderberry taken without oseltamivir did about two days worse than placebo.
Often saidElderberries are poisonous.
ActuallyCooked ripe black elderberries are eaten across Europe as syrup, wine and jam. The caution belongs to raw or unripe fruit and to the leaves, stems, bark and roots. NCCIH's guidance is that cooking eliminates the toxin, and the 1983 California poisoning involved raw juice pressed with leaves and stems included.
Often saidElderberry overstimulates the immune system and could trigger a cytokine storm.
ActuallyThis spread during COVID-19 from cell-culture cytokine data rather than from patients. Wieland's 2021 review found no evidence of immune overstimulation in the trials to date. The accurate statement is that the question has not been tested properly, not that the danger has been shown.
Who profits, and who pushes back
L. Susan Wieland, PhD
Wieland and colleagues concluded that elderberry may shorten the duration of cold and influenza symptoms, but rated the certainty of that evidence low to very low, citing small samples, dropouts, selective reporting, and sponsorship of included trials by elderberry manufacturers.
Michael Macknin, MD
Macknin's team reported no evidence that elderberry extract benefited the duration or severity of influenza, and noted a post hoc finding that patients taking elderberry without oseltamivir fared about two days worse than those on placebo alone.
National Center for Complementary and Integrative Health
NCCIH states that only a small number of studies have evaluated elderberry for colds and flu, that preliminary research suggests it may relieve symptoms, and that raw or unripe berries, leaves and stems contain cyanide-producing substances which cooking eliminates.
Stefan Gafner, PhD
Gafner co-authored the BAPP bulletin reporting that elder berry extracts are commonly adulterated with undisclosed black rice extract, which can be many times cheaper, and with other anthocyanin-rich extracts or purple colourants.
Where the research comes from
Most of the published research on this comes from one place. 100% of it is from Native to Europe, western Asia and North Africa, naturalised widely, with the largest modern market in North America.. Findings that no unrelated group has reproduced are weaker than the study count makes them look.
| Place | Share of published research |
|---|---|
| Native to Europe, western Asia and North Africa, naturalised widely, with the largest modern market in North America. | 100% |
How we got here
Pliny's Sambucus gave the genus its Latin name, probably by way of the Greek sambuca, a stringed instrument said to have been made from the hollow stems, while the English elder comes from an Anglo-Saxon root tied to fire, since the pithy stems were cleaned out and used as blowpipes to raise a flame. The taxonomy has drifted more than the folk names have: American elder circulated as Sambucus canadensis for two centuries and is now usually treated as a subspecies of S. nigra, which matters commercially because North American product and European product carry the same label while differing in chemistry. Modern elderberry's clinical reputation descends almost entirely from one branded syrup, Sambucol, developed in Israel and tested there and in Norway, and the category that grew after it now sits on the same trials.
Elder is one of the oldest documented European medicines. Hippocratic writers around 400 BCE recommended it for constipation, dropsy and menstrual complaints, and Pliny the Elder described Sambucus in the Naturalis Historia in the first century CE, crediting it with diuretic action. The Greek name sambuca, which gave the genus its name, is usually linked to a stringed instrument, while the English word elder traces to an Anglo-Saxon root associated with fire, from the practice of hollowing out the pithy stems into blowpipes for kindling. Anglo-Saxon and Welsh leechbooks used both flower and berry, as did the Salerno school in Italy. The seventeenth-century physician Michael Ettmüller is credited with the phrase that stuck to it, the medicine chest of the country people, which describes the plant's role better than any single indication does.
- c. 400 BCEHippocratic writers recommend elder for constipation, dropsy and menstrual complaints
- 1st c. CEPliny the Elder describes Sambucus in the Naturalis Historia and credits it with diuretic properties
- 17th c.Michael Ettmüller is credited with calling elder the medicine chest of the country people
- Aug 1983Eight of 25 people in Monterey County, California fall ill after drinking raw juice pressed from Sambucus mexicana berries, leaves and stems; the CDC reports the outbreak in MMWR
- 1995 and 2004Zakay-Rones publishes two small influenza trials of a branded elderberry syrup, in Israel and Norway, both reporting recovery about four days earlier
- 2016Tiralongo's trial in 312 Australian air travellers reports shorter, milder colds using a manufacturer-supplied extract
- 2020Macknin's emergency-room trial finds no influenza benefit, while COVID-19 demand makes elderberry a top-selling supplement ingredient
- 2021Wieland's systematic review rates the evidence low to very low certainty; BAPP reports 10.9% of 532 commercial elderberry samples failing identity testing
How it is understood
Elder occupies an unusual position in European folk belief, useful and slightly dangerous. In Danish and English tradition an Elder Mother, Hyldemoer in Denmark, the Old Girl in Lincolnshire, inhabits the tree, and woodsmen asked her permission before cutting. Elsewhere the tree was planted by a door to keep witches out, and elsewhere again witches were said to gather beneath it. The berries went into the household year as syrup, wine and preserve, the flowers into cordial, and the plant was the closest a rural household had to a pharmacy.
At a glance
- Botanical name
- Sambucus nigra L., family Viburnaceae (formerly Adoxaceae)
- Marker compound
- Cyanidin-3-O-sambubioside, the anthocyanin used for identity testing
- Best evidence
- 5 RCTs, about 624 participants, GRADE certainty low to very low (Wieland, 2021)
- Market integrity
- 58 of 532 commercial samples (10.9%) failed identity specifications (BAPP)
What this entry does not yet cover
What follows is unfinished work on our side, not a finding about Elderberry (Sambucus nigra, Holunder, Sureau). A short entry is not a safe entry.
- Cost and market. We have not documented what it sells for or who sells it.
- Supply chain. We have not mapped where it is made.
- Who uses it. We have not documented the user groups.
- What could change. No forward-looking summary yet.
- How it compares. We have not set it against the alternatives.
- Children and teenagers. We have not checked what is known about younger people.
- What people take it for. We have not catalogued the claims made for it.
Sources
Five RCTs, roughly 624 participants; cold duration about 2 days shorter, influenza recovery nearly 3 days shorter; GRADE certainty low to very low; sponsors included Iprona AG and Bioforce AG
Meta-analysis of randomised trials reporting that elderberry substantially reduces upper respiratory symptom duration
No benefit of elderberry extract on influenza duration or severity; post hoc signal of about 2 days worse without oseltamivir
312 air travellers; elderberry extract associated with shorter cold duration and reduced symptom score
Two early influenza trials, 60 patients in Norway, symptoms relieved on average four days earlier
Raw or unripe berries, leaves and stems contain cyanide-producing substances; cooking eliminates the toxin; only a small number of studies have evaluated elderberry for colds and flu
National Center for Complementary and Integrative Health, Elderberry
1983 Monterey County, California outbreak after drinking raw juice pressed from Sambucus mexicana berries, leaves and stems; eight of 25 hospitalised
Elderberry extracts commonly adulterated with black rice extract and other anthocyanin sources; 58 of 532 commercial samples failed identity testing
Species differences in cyanogenic glycosides; S. nigra ssp. canadensis berries and leaves shown to lack them; S. racemosa seeds poisonous; 1983 incident argued not to be cyanide
Sambucus, Wikipedia (citing the underlying phytochemical analyses)
Hippocrates and Pliny on elder; medieval and early-modern European use; witch-protection folklore
Elder Mother folklore, Danish Hyldemoer, the Lincolnshire Old Girl, and asking permission before cutting elder wood
Elder called the medicine chest of the country people; etymology of elder and Sambucus; historical European use of flower and berry
Bioactive compounds and subspecies chemistry of Sambucus nigra