Role of Echinacea in the management and prevention of acute respiratory tract infections in children: A systematic review of the evidence

Abstract

Acute cough and respiratory tract infections (RTIs), common in children, often lead to high antibiotic use. Echinacea, an herbal alternative, has been studied for its immune-modulating and antiviral effects to reduce the unnecessary use of antibiotics. This systematic review analyzed randomized controlled trials on Echinacea for pediatric acute cough and RTIs. PubMed, Cochrane Library, Semantic Scholar, and Google Scholar were searched on October 15, 2024. Five studies met all inclusion criteria and were retained for qualitative synthesis. The studies generally showed some concerns of bias in randomization and allocation concealment, as well as some issues about blinding and selective reporting. Grading of recommendations assessment, development, and evaluation assessment indicated high certainty of the reduction of symptom duration and antibiotic use, and moderate certainty for the prevention of infection. Evidence suggests that Echinacea purpurea, especially at higher doses (e.g., 2000 mg/day), may reduce RTI incidence, viral load, and symptom severity. Several trials have reported fewer antibiotic prescriptions and shorter fever duration, indicating public health benefits. Efficacy varied by formulation, extraction, and dosing, with tablet-based and hydroethanolic extracts showing more consistent results. Echinacea was well tolerated, only producing mild adverse effects of gastrointestinal discomfort and skin rashes. Some studies showed no significant difference from placebo, which underlines the need for standardized dosing and formulation. Overall, Echinacea may be a useful adjunct for pediatric RTI prevention and management, but further large, high-quality trials are needed to confirm optimal use, efficacy, and safety.

Introduction

Echinacea is being increasingly used as a natural treatment to prevent and manage respiratory infections and coughs in children.[1] Its main species, Echinacea purpurea, is valued for its immune-boosting and anti-inflammatory properties. The herbal supplement is believed to stimulate macrophages and cytokine production, enhancing the body’s antiviral response and potentially reducing infection rates, symptom severity, and duration.[2] Several studies suggest that Echinacea may also lower viral loads and decrease the need for antibiotics, which is beneficial, given the global challenge of antimicrobial resistance (AMR).[3]

Recent systematic reviews and meta-analyses have highlighted Echinacea’s significant potential in respiratory tract infection (RTI) management. Large-scale analyses indicate that Echinacea supplementation can reduce the incidence of RTIs, recurrent episodes, and complications, with some studies reporting a substantial decrease – up to 70% – in antibiotic use, particularly when alcoholic extracts of E. purpurea are used. While most evidence supports a preventive effect and a modest reduction in symptom duration, the overall benefit in children remains less certain owing to methodological heterogeneity and the predominance of adult-focused research. Importantly, Echinacea demonstrates a safety profile comparable to placebo, with no significant increase in adverse events across populations.[4,5,6]

Despite promising results, safety remains an important consideration. Most research indicates Echinacea is well tolerated in children, but some may experience allergic reactions, particularly if sensitive to plants from the Asteraceae family, such as chamomile and ragweed.[7,8] Mild side effects such as gastrointestinal discomfort and skin rashes have also been reported, emphasizing the need for careful formulation and dosing.[8] The risk of allergic hypersensitivity is especially relevant in children with known allergies, and some studies recommend caution when prescribing Echinacea to such children.

The variability in study outcomes is partly due to differences in herbal formulations, plant parts used, extraction techniques, and dosing regimens. Some trials show significant reductions in respiratory symptoms and viral loads, while others report no notable benefits.[8] This inconsistency highlights the importance of establishing standardized protocols for Echinacea use in pediatrics, such as appropriate dosing, formulation, and duration of treatment.[1]

Overall, Echinacea could serve as a supportive, herbal option for reducing respiratory infections and antibiotic use in children. However, additional large-scale, high-quality studies are necessary to confirm its safety and efficacy. Clinicians should individualize recommendations, monitor patients for adverse reactions, and consider allergy risks, particularly when using Echinacea long-term or in high doses.[1,2,7,8]

Previous systematic reviews on Echinacea for respiratory infections have mainly focused on adults or combined adult and pediatric data, without analyzing children separately. Needless to say, children differ from adults in immune response, infection patterns, and safety considerations. This review addresses the gap by exclusively evaluating the efficacy of Echinacea’s and its safety in children, providing age-specific evidence to guide pediatric care. Such focused analysis is necessary because outcomes and optimal use may differ in pediatric populations compared to adults.[4,5,6]

Aim of the review

This review evaluates the benefits and risks of Echinacea for acute cough in children, focusing on evidence from recent randomized controlled trials (RCTs). It examines effects on the duration of the cough, its severity, safety, and contraindications, aiming to improve understanding and guide clinical use of Echinacea in pediatric respiratory care.

Importance of the review

This review addresses the increasing use of herbal therapies such as Echinacea for children’s cough, amid concerns over the efficacy and safety of traditional treatments, especially for young children. It highlights issues with unregulated cough syrups and excessive antibiotic use contributing to AMR. There are issues with the widespread use of Echinacea owing to the lack of standardized dosages, inconsistent study methodologies, and the variable quality of herbal preparations, which hinder reliable data. The review aims to analyze high-quality clinical studies, evaluate their strengths and limitations, and identify research gaps to improve understanding and clinical application of Echinacea for pediatric cough treatment.

Methodology

Search strategy

A systematic and comprehensive search was conducted across four scientific and medical databases specializing in herbal medicine and pediatric respiratory health: PubMed (National Library of Medicine), Cochrane Library (Cochrane Central Register of Controlled Trials – CENTRAL), Semantic Scholar, and Google Scholar. The search was done on October 15, 2024, to identify relevant studies published between January 2000 and October 2024. The search strategy focused on capturing evidence related to Echinacea’s effects on cough and respiratory infections in children, utilizing a combination of keywords and MeSH terms such as “Echinacea,” “Echinacea purpurea,” “Echinacea pallida,” “Echinacea angustifolia,” “Echinacea extract,” “Echinacea supplementation,” and “Herbal medicine.” Boolean operators were employed to combine these terms with disease-specific keywords, including “Cough,” “Acute cough,” “Upper respiratory tract infection,” “Common cold,” and “Pediatric respiratory infection,” as well as study design filters such as “Randomized controlled trial,” “RCT,” “Clinical trial,” “Placebo-controlled trial,” “Double-blind study,” and “Dose–response study.” In addition, the search was limited to studies involving children or pediatric populations using the terms “children” OR “pediatric,” and only English-language publications were considered. All retrieved records were uploaded to Covidence software (Covidence, Melbourne, Australia) for efficient and transparent screening and management of the review process.

Inclusion and exclusion criteria

Eligible studies included children aged 1–12 years who presented with acute cough or RTIs, as defined by Jackson’s criteria. This required the presence of at least one of four cold-related symptoms – nasal discharge, nasal obstruction, sneezing, or sore throat – or a Jackson score of 2 or higher on a scale from 0 to 3. In addition, studies were required to evaluate Echinacea as the primary intervention, compared to placebo, Vitamin C, or standard care. To minimize confounding effects and reduce potential risks, studies involving participants with chronic respiratory, autoimmune, metabolic, or immunosuppressive conditions were excluded. This approach ensured that the analysis focused specifically on children with acute respiratory infections, thereby enhancing the reliability and clinical relevance of the findings.

Review process

The review process for this systematic review was designed to ensure methodological accuracy, consistency, and completeness, guided by a structured template based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane guidelines.[9] All relevant data, including study design, sample size, follow-up period, and intervention specifics (such as Echinacea species, formulation, dosage, treatment duration, and extraction method), were independently extracted by two reviewers (AM and RA), who cross-checked findings to resolve discrepancies and maintain reliability. A checklist was utilized to confirm data completeness and accuracy, and duplicate checks were performed throughout. Data were managed using systematic review software and Excel for efficient organization and accessibility. The methodological rigor of included studies was further evaluated using the Cochrane risk-of-bias tool, version 2.0, focusing on randomization, allocation concealment, blinding, data completeness, and selective reporting.[10] In addition, the quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to determine the certainty of findings.[11] This comprehensive approach ensured the integration of high-quality evidence and supported a robust analysis of Echinacea interventions in pediatric populations.

Outcome measures

Primary outcomes included cough duration, symptom severity, and safety profiles. Secondary outcomes focused on the reduction of antibiotic use and adverse event rates. Viral load measurements and immunomodulatory effects were additionally analyzed where available.

Statistics

Data synthesis followed Cochrane Handbook guidelines, with qualitative analysis of RCT outcomes. Effect sizes, confidence intervals, and P values were extracted for key metrics (e.g., infection rates, symptom duration). Heterogeneity in study designs precluded meta-analysis, necessitating a narrative synthesis.

Protocol registration

The review protocol was prospectively registered in PROSPERO (CRD420251010546) to enhance transparency and minimize bias.

Results

Study selection process

The systematic review identified 687 studies from electronic databases and 25 additional records from other sources, yielding an initial pool of 712 articles. Following deduplication, which removed 200 overlapping records, 512 unique studies underwent title and abstract screening. Eligibility criteria required RCTs or clinical trials involving children aged 1–12 years with acute cough or RTIs, where Echinacea was the primary intervention (vs. placebo, Vitamin C, or standard care). Outcomes of interest included infection rates, symptom severity, illness duration, or viral load reduction, with only peer-reviewed English studies. Screening excluded 390 irrelevant articles, leaving 122 for full-text assessment. During this phase, 30 studies were excluded for non-RCT designs, 46 for mixed adult/child cohorts without pediatric-specific data, 17 for multi-ingredient formulations obscuring Echinacea’s independent effects, and 24 for lacking defined outcome measures. Ultimately, five studies met all inclusion criteria and were retained for qualitative synthesis [Figure 1].

Figure 1.

Preferred reporting items for systematic reviews and meta-analyses flow diagram

Bias assessment in the included studies

Methodological quality was appraised using the Cochrane risk of bias tool, with emphasis on randomization, allocation concealment, blinding, data completeness, and outcome reporting. Most trials exhibited low risk of bias in randomization and allocation concealment, reflecting rigorous assignment protocols. For instance, Ogal et al., implemented computer-generated randomization with concealed allocation, effectively minimizing selection bias.[3] Conversely, Taylor et al., documented allocation concealment inadequately, raising concerns about potential selection bias.[8] Blinding practices varied: Cohen et al.’s explicit description of double-blind methodologies ensured low risk of performance bias.[12] On the other hand, Weishaupt et al., provided insufficient detail on outcome assessor blinding, leaving detection bias unresolved.[13] Attrition bias was generally mitigated through intention-to-treat analyses, though incomplete handling of missing data in some studies weakened this domain. Selective reporting bias was minimal, as outcomes aligned with pre-registered protocols; however, Taylor et al.’s incomplete report of the adverse effects beyond the incidence of rash introduced uncertainty in safety evaluations.[8] The Weber et al’s study shows a moderate overall risk of bias. Randomization was appropriate, using block randomization to balance groups. However, allocation concealment is somewhat unclear because of the limited detail in the process. Blinding of participants and staff was well maintained, but outcome assessment gave some concern since diagnoses relied on parent-reported symptoms rather than clinical or laboratory confirmation. Incomplete outcome data posed low risk, with only a small proportion of missing logbooks of only 25 out of 426, representing a 6% attrition rate. The main limitation is selective reporting, as this was a secondary analysis of a trial originally designed for treatment rather than prevention, and there was no pre-registered protocol for prevention outcomes. In addition, a higher rate of rash was observed in the Echinacea group, raising potential safety concerns.[14] Overall, most trials were judged to have some concerns on the risk of bias, with only a few demonstrating low risk of bias. Minor limitations in blinding and adverse event reporting necessitate cautious interpretation of results [Figure 2].

Figure 2.

Risk of bias assessment of the included studies

A comparative analysis of Echinacea interventions for pediatric acute cough across five RCTs collectively included 1640 children, demonstrating rigorous methodologies and varying sample sizes between 79 and 524 participants. Notably, Cohen et al., conducted a two-arm, double-blind, placebo-controlled RCT in 430 children aged 1–5 years, randomizing participants at a 1:1 ratio to either an herbal preparation containing Echinacea or placebo for prophylactic evaluation.[12] Ogal et al., similarly employed a preventive design with 200 children aged 4–12 years, utilizing a double-blind, randomized allocation at a 1:1 ratio between Echinacea extract (1200 mg) and Vitamin C (50 mg).[3] In one of the treatment-focused studies, Taylor et al., enrolled 407 children aged 2–11 years in a double-blind, placebo-controlled trial, assigning participants to Echinacea or placebo for up to three upper respiratory infections (URIs).[8] Weishaupt et al., examined respiratory outcomes in 79 children aged 4–12 years, utilizing block randomization to assign participants to high (2000 mg) or low (1200 mg) Echinacea doses or control groups.[13] In the randomized, double-blind, placebo-controlled trial by Weber et al., 524 children aged 2–11 years were enrolled and randomized to receive either E. purpurea (as a reconstituted dried juice of the above-ground plant parts) or placebo during episodes of acute URI. Of these, 401 children were included in the primary analysis, with 197 assigned to Echinacea and 204 to placebo. The dosing regimen was age-adjusted and administered for up to 10 days per infection episode [Table 1].[14]

Table 1.

Comparative analysis of Echinacea interventions in pediatric acute cough: Study design, Sample size, follow-up duration, and extraction methods for studies included in systematic review

Study	Design	Sample size	Age	Comparative groups	Follow-up duration	Intervention	Extraction method
Taylor et al.[8]	RCT, blinded	407	2–11 years	Echinacea versus. placebo	10 days	Echinacea syrup (7.5 mL/day for ages 2–5; 10 mL/day for ages 6–11, for 10 days)	Alcohol-free pressed juice extract
Cohen et al.[12]	RCT, placebo-controlled	430	1–5 years	Echinacea-Vitamin C versus placebo	12 weeks	Echinacea syrup (5 mL twice daily for ages 1–3; 7.5 mL twice daily for ages 4–5)	Likely mild ethanol or water-based extraction
Weber et al.[14]	RCT, double-blind	524	2–11 years	Echinacea versus placebo	4 months	E. purpurea reconstituted dried juice of aerial plant parts, 3/4 Tsp (87.75 mg) or 1 Tsp (117 mg) BID for up to 10 days per URI	Alcohol-free pressed juice extract containing 23.4 mg/mL of dried extract
Weishaupt et al.[13]	Multicenter RCT	79	4–12 years	Echinacea (low dose versus high dose)	Acute treatment period	Echinaforce junior tablets (1200 mg/day versus 2000 mg/day for acute cold episodes)	Hydroethanolic (65% ethanol)
Ogal et al.[3]	RCT, Blinded	200	4–12 years	Echinacea versus Vitamin C (50 mg daily)	4 months	Echinaforce junior tablets (400 mg, 3 × daily for 4 months, with 1-week break)	Hydroethanolic (65% ethanol)

RCT=Randomized control trials, BID=Twice daily; Tsp=Teaspoon, URI=Upper respiratory infection, E. purpurea: Echinacea purpurea

Description of the intervention

Echinacea has gained widespread use for its potential benefits in managing pediatric upper RTIs and acute cough. Although several species – including E. purpurea, Echinacea pallida, and Echinacea angustifolia – have been investigated, E. purpurea stands out as the most commonly studied in children, primarily owing to its established immunomodulatory and anti-inflammatory properties. All studies included in this review specifically examined E. purpurea, reflecting its dominance in pediatric respiratory research. Notably, the studies varied in terms of the plant parts utilized, extraction techniques, and final formulations. Some investigations employed whole-plant extracts, while others combined aerial components (such as leaves and flowers) with roots. For instance, Weishaupt et al., and Ogal et al., utilized E. purpurea extracts standardized to 95% aerial parts and 5% roots, a typical ratio in herbal preparations.[3,13] Whereas Taylor et al., and Cohen et al., used alcohol-free pressed juice syrup derived from aerial parts, formulated specifically for pediatric administration. Root extracts are valued for their high concentrations of alkamides and polysaccharides, while aerial parts are rich in flavonoids and polyphenols, both of which are associated with antiviral and anti-inflammatory effects.[8,12] Furthermore, Weber et al., utilized Echinacin® Saft, a standardized, alcohol-free liquid preparation made from the reconstituted dried pressed juice of E. purpurea aerial parts. This extract, produced by Madaus AG in Germany at a concentration of 23.4 mg/mL, was approved by the German Commission E for supportive care in colds. The manufacturing process involved mechanical pressing and gentle evaporation of fresh plant material, followed by reconstitution for pediatric administration. This ensured a consistent and well-characterized product for use during acute URIs over a 4-month observation period.[14]

The extraction methods employed across studies also varied, impacting the bioavailability and effectiveness of Echinacea’s bioactive constituents. Weishaupt et al., and Ogal et al., utilized hydroethanolic extraction (65% ethanol), recognized for its cost-effectiveness, while other studies produced alcohol-free pressed juice extracts to preserve natural components and ensure safety for young children.[3,13]

The specific interventions also differed: Ogal et al., and Weishaupt et al., evaluated Echinaforce® Junior tablets, a preparation commonly used in European herbal medicine,[3,13] whereas Taylor et al., Weber et al., and Cohen et al., used syrup formulations suitable for children unable to swallow tablets.[8,12,14] Notably, Cohen et al.’s extract included aerial parts of E. purpurea and roots of E. angustifolia with age-adjusted dosages – children aged 1–3 years received 5.0 mL twice daily, and those aged 4–5 years received 7.5 mL twice daily.[12] Dosing regimens and timing also varied: Ogal et al., prescribed 400 mg tablets three times daily over 2-month cycles with 1-week break as a preventive measure, whereas Weishaupt et al., conducted a dose–response trial with a low-dose group (1200 mg/day, 3 tablets) and a high-dose group (2000 mg/day, 5 tablets), initiating treatment 10 days after symptom onset, with higher doses associated with shorter symptom duration.[3,13] Taylor et al., adjusted syrup doses by age, administering 7.5 mL/day for children aged 2–5 years and 10 mL/day for those aged 6–11 years, for 10 days after symptom onset.[8] In the Weber et al.’s trial, the intervention consisted of a non-alcoholic liquid formulation of E. purpurea (Echinacin® Saft, Madaus AG, Germany), standardized to 23.4 mg/mL using age-specific dosage: children aged 2–5 years received — teaspoon (87.75 mg) twice daily, while those aged 6–11 years received 1 teaspoon (117 mg) twice daily. Treatment was administered for up to 10 days per acute infection episode during a 4-month observation period.[14] These variations in formulation, dosing, and administration highlight the diversity in Echinacea interventions for pediatric respiratory conditions [Table 1].

Recent studies evaluating Echinacea in children with acute cough and respiratory infections report promising preventive effects. Ogal et al., found that Echinacea reduced RTI episodes by 32.5%, antibiotic use by 76.3%, and influenza detections (3 vs. 20, P = 0.012), with fewer adverse events than Vitamin C, supporting its use for long-term immune support.[3] Conversely, Taylor et al., saw no significant impact on cold duration or severity (median 9 days, P = 0.89) but did note a higher incidence of rash (7.1% vs. 2.7%, P = 0.008), advising caution in acute treatment.[8] Weishaupt et al., reported that higher doses (2000 mg/day) shortened cold duration by 1.7 days and reduced antibiotic prescriptions, suggesting benefit with early, higher-dose use.[13] Cohen et al., demonstrated a 55% reduction in RTI episodes and fewer fever days (2.1 vs. 5.4, P < 0.001), supporting seasonal prophylaxis.[12] Weber et al., found a 28% lower risk of recurrent URIs and longer intervals between episodes (46 vs. 38 days, P = 0.01) with E. purpurea, though further trials are needed to confirm these preventive effects.[14] Overall, Echinacea appears to reduce the frequency and severity of infection in children, particularly for prevention, but caution is warranted regarding adverse effects, and recommended also is more research [Table 2].

Table 2.

Outcomes, effects, and recommendations of Echinacea in pediatric acute cough and respiratory infections for studies included in systematic review

Study	Outcomes measured	Effect of Echinacea	Recommendations
Taylor et al.[8]	Duration and severity of cold symptoms	No significant difference in symptom duration or severity (median 9 days, P=0.89). Increased rash incidence (7.1% versus 2.7%, P=0.008)	Echinacea is not effective for acute treatment of colds in children; caution advised due to increased risk of rash
Cohen et al.[12]	Infection episodes, fever duration, illness days	55% reduction in RTI episodes, fever days reduced (2.1 vs. 5.4 days, P<0.001), and total illness days significantly lower	Echinacea-based herbal formulations may improve immune defense; recommended for seasonal RTI prevention
Weber et al.[14]	Incidence of a second tract URI - time to subsequent URI	28% decrease in risk of URIs compared to placebo (P=0.01) longer median time to next URI (46 vs. 38 days) supported by survival/cox analysis	Echinacea is effective in reducing respiratory infections and is recommended
Weishaupt et al.[13]	Cold duration, symptom resolution, antibiotic use	Higher doses (2000 mg/day) reduced cold duration by 1.7 days, increased symptom resolution, and lowered antibiotic prescription (4.6%)	Higher doses improve outcomes and are recommended for early intervention in cold episodes
Ogal et al.[3]	RTI frequency, antibiotic use, viral load, adverse events	Reduced RTI episodes by 32.5%, decreased antibiotic use by 76.3%, reduced viral infections (influenza 3 vs. 20 detections, P=0.012), fewer adverse events than Vitamin C	Echinacea is effective for preventing RTIs and reducing antibiotic use in children; it is recommended for long-term immune support

URIs=Upper respiratory infections, RTI=Respiratory tract infection

Current evidence highlights E. purpurea’s potential role in pediatric respiratory infections, though outcomes vary across studies. Ogal et al., demonstrated that Echinacea reduced RTI episodes by 32.5% and antibiotic prescriptions by 76.3%, together with fewer complications such as sinusitis and pneumonia.[3] Conversely, Taylor et al., found no significant difference in symptom duration between Echinacea and placebo groups, though a higher incidence of rash was observed in the treatment group (7.1% vs. 2.7%, P = 0.008).[8] Dose-dependent effects were evident in Weishaupt et al., where higher doses (2000 mg/day) shortened cold duration by 1.7 days and improved the resolution of symptoms.[13] Cohen et al., noted that a combination of Echinacea, propolis, and Vitamin C reduced illness episodes by 55% and fever duration by 62%, though the isolated impact of Echinacea remained unclear.[12] Weber et al., reported a statistically significant 28% decrease in the incidence of a second URI with Echinacea versus placebo (P = 0.01).[14] However, interpretation is limited by secondary analysis design, reliance on parent-reported symptoms without clinical confirmation, and incomplete symptom diary data [Table 3].

Table 3.

Medical evidence supporting the use of Echinacea in pediatric respiratory infections

Study	Medical evidence
Taylor et al.[8]	No significant difference in symptom duration between Echinacea and placebo. However, an increased risk of rash was noted (7.1% vs. 2.7%, P=0.008)
Cohen et al.[12]	A combination of Echinacea, propolis, and Vitamin C reduced illness episodes by 55% and fever duration by 62%. However, the effect of Echinacea alone was not isolated
Weber et al.[14]	Statistically significant 28% reduction in incidence of a second URI compared to placebo (P=0.01). The Echinacea group in the survival analysis also showed greater time to URI recurrence. However, the analysis is constrained by its secondary nature, parent-reported symptoms without clinical validation, and the absence of data from symptom diaries
Weishaupt et al.[13]	Higher doses (2000 mg/day) of E. purpurea reduced cold duration by 1.7 days and showed better symptom resolution compared to lower doses
Ogal et al.[3]	E. purpurea lowered RTI episodes by 32.5% and antibiotic prescriptions by 76.3% while also reducing complications such as sinusitis and pneumonia

E. purpurea: Echinacea purpurea, RTI=Respiratory tract infection

Certainty of evidence (grading of recommendations assessment, development, and evaluation)

The GRADE assessment indicates high certainty of the reduction of cold symptoms (1.7 days) and the use of antibiotics (76.3% reduction), with fewer antibiotic courses required. Moderate certainty supports a 32.5% decrease in secondary infections and a 28% reduction in recurrent URIs, along with a longer median time to recurrence in the Echinacea group. Overall, evidence is strengthened by randomized, double-blind designs but limited by reliance on secondary analyses, parent-reported symptoms, and incomplete symptom diaries. These findings underscore Echinacea’s potential to mitigate symptom burden and reduce reliance on antibiotics, though variability in the certainty of evidence highlights the need for further standardization in the measurement of outcome [Table 4].

Table 4.

Certainty of evidence grading of recommendations assessment, development, and evaluation

Outcome	Effect	Certainty of evidence	Notes
Incidence of cold infection	28% reduction	Moderate	Based on secondary analysis due to data missing
Cold symptom duration	Reduced by 1.7 days	High	Significant reduction in cold duration with Echinacea
Secondary infections (e.g., sinusitis, pneumonia)	Reduced by 32.5%	Moderate	Echinacea significantly reduces complications compared to control
Antibiotic use	76.3% reduction	High	Significant reduction in the need for antibiotics, with fewer courses required
Adverse effects	Mild, transient (rash, gastrointestinal issues)	Moderate	Few mild side effects observed, but no severe adverse effects reported

Discussion

Coughs remain the most frequent reasons for pediatric healthcare consultations globally, with prevalence estimates varying from 4.7% to 60% depending on the setting and the season.[15] An acute cough, often linked to URIs, croup, bronchiolitis, whooping cough, and pneumonia, accounts for nearly 90% of cases in children, while a chronic cough (lasting ≥4 weeks) affects 5%–26% and is frequently associated with conditions such as asthma, protracted bacterial bronchitis, or gastroesophageal reflux.[16,17,18,19] Beyond its clinical burden, a cough contributes significantly to childhood morbidity, with pertussis alone causing an estimated 160,700 deaths annually in children under five.[20]

The highest cough incidence occurs in winter, especially January and February, and varies from 4.7% to 23.3% of pediatric consultations, with some studies reporting rates up to 60%.[21] Such a prevalence places a substantial burden on children, families, and healthcare systems. Young children are especially at risk owing to immature immunity, frequent exposure in group settings, and narrower airways, leading to increased inflammation and complications such as bacterial superinfections and hospitalizations – particularly among those with comorbidities. Persistent symptoms disrupt daily life and heighten parental anxiety, often resulting in unnecessary antibiotic use that contributes to AMR. These illnesses also generate significant healthcare costs and productivity losses. Thus, there is a critical need for safe, effective, and accessible therapies to manage symptoms and reduce antibiotic overuse, and natural options like Echinacea are being explored for their potential benefits in pediatric respiratory care.[16,17]

Herbal medicines such as Echinacea, Pelargonium, Licorice root, and Thyme have long been used to treat acute coughs and respiratory illnesses, demonstrating anti-inflammatory effects and immune-boosting properties to aid recovery from viral infections.[22] Healthcare providers are increasingly considering herbal options such as Echinacea as antibiotic alternatives for high-risk populations, including children. Five RCTs indicate potential benefits in preventing respiratory infections, lowering viral loads, curbing antibiotic misuse, and easing symptoms, though efficacy depends on product formulation, dosage, and study methodology. Current evidence underscores the need for robust clinical trials to validate safety and therapeutic value in pediatric care. Unregulated herbal use poses safety risks from unstandardized products, ambiguous dosing, and drug interactions, complicating outcome assessment. Establishing standardized Echinacea formulations could advance evidence-based natural therapies, offering safer immune support, reducing antibiotic reliance, and improving respiratory infection management in children.[23]

The integration of Echinacea into evidence-based strategies could offer systemic benefits if clinical trials confirm its capacity to reduce infection rates and enhance immune responses. Such validation might decrease reliance on conventional medications, ease healthcare burdens, and combat AMR. Physicians’ overprescription of antibiotics – particularly for viral infections – remains a concern, and adopting nontoxic herbal alternatives like Echinacea could mitigate this issue. Regulation of pediatric herbal use would also minimize risks of misuse (e.g., inappropriate dosing) and improve synergy with conventional therapies and thereby foster safer complementary approaches in respiratory care.

This systematic review highlights Echinacea’s notable impact on preventing upper RTIs during peak viral seasons in children. Ogal et al., reported a 32.5% reduction in recurrent infections of children taking Echinacea tablets versus Vitamin C, underscoring its significant immune-supportive properties[3] while Weber et al., reported a longer median interval to the next infection (46 days compared to 38 days) in the Echinacea group.[14]

A placebo-controlled trial of children taking Echinacea–propolis–Vitamin C syrup, revealed an astounding 55% reduction in infection episodes.[12] These results align with Weber et al., who reported 28% reduction in viral infections in children given E. purpurea (Echinacin® Saft) at 87.75 mg or 117 mg twice daily for up to 10 days per infection episode.[14] Replicated findings suggest that Echinacea may be better suited for prolonged prophylactic use than acute treatment in infection prevention. However, heterogeneity in dosing, duration, and control groups across studies implies its efficacy is context-specific, requiring optimized protocols that account for individual factors like immune status and prior infection history. Studies indicate that Echinacea can significantly reduce viral loads and shorten cold duration. Nicolussi et al., reported a 98.5% viral load reduction, and Weishaupt et al., found faster symptom resolution at higher doses.[13,24] However, results vary, especially in children using syrup forms, which showed no notable benefit compared to placebo, which is likely to be due to differences in extraction, concentration of the active ingredient, and adherence to instructions. Tablet-based formulations tend to provide more consistent immune benefits. Overall, Echinacea shows antiviral potential, but its clinical effectiveness depends on standardized dosing, treatment timing, and formulation bioavailability.[3,13]

Limited RCTs explore Echinacea as adjunctive therapy, with insufficient data on its interactions with antipyretics or antibiotics. Current aggressive fever management practices in viral respiratory infections often drive unnecessary healthcare visits. This review proposes that Echinacea may moderate inflammatory pathways and decrease antibiotic demand, though further clinical validation is needed. Cohen et al., found that Echinacea–propolis–Vitamin C syrup reduced the duration of fever in children from 5.4 to 2.1 days, indicating its immune-modulating and anti-inflammatory effects.[12] Despite using a multi-herbal formulation, findings indicate Echinacea’s potential role in managing febrile conditions. Ogal et al., observed a 76.3% decrease in antibiotic prescriptions for children using Echinacea tablets, suggesting it could mitigate unnecessary antibiotic use and combat AMR.[3] These outcomes imply Echinacea may enhance immune responses, lessen infection severity, and reduce dependence on antibiotics in pediatric viral respiratory infections, and thus offer avenues to refine clinical practices and public health strategies.[3,12]

These findings could inform clinical guidelines and public health strategies, particularly for pediatric populations with frequent viral infections. Echinacea’s capacity to enhance immune responses while reducing antibiotic overuse risks positions it as a promising option for the mitigation of the severity of infections and curbing of AMR. Echinacea’s efficacy in preventing and treating pediatric respiratory infections varies across studies, mainly as a result of differences in formulation, dosage, and extraction methods that influence its bioactive components and potency.[3,13,14] Echinacea tablets demonstrate superior efficacy compared to syrups in pediatric studies. Ogal et al., reported a 32.5% reduction in respiratory infection episodes and a 76.3% decline in antibiotic prescriptions in children, while Nicolussi et al., noted a 98.5% viral load decrease in the mixed population.[3,24] Syrup formulations showed inconsistent results: Cohen et al., observed a 55% reduction in illness episodes with a multi-ingredient syrup, whereas Taylor et al., found no symptom improvement versus placebo.[8,12] In addition, Weber et al., reported a more modest 28% reduction in RTI incidence with Echinacea syrup.[14] These disparities highlight formulation-dependent effectiveness, potentially linked to absorption variability and challenges of adherence in the use of syrups.[8,12,14] These results indicate that tablet-based formulas offer better immune support than syrup-based ones.

Echinacea’s efficacy in children is influenced by dose, timing, and extraction. Higher doses (e.g., 2000 mg/day) are linked to faster recovery and reduced symptoms, while inconsistent or lower doses (e.g., 7.5 mL/day) may lessen effectiveness.[13]

Proper dosing is key, as low doses offer limited benefit. Extraction methods impact efficacy –65% hydroethanolic extracts preserve active compounds such as alkamides and flavonoids, enhancing antiviral and anti-inflammatory effects, as shown in studies by Ogal et al., Weber et al., and Weishaupt et al.[3,13,14] Alcohol-free pressed juice is less potent, which may explain reduced effectiveness. Standardization of dose, formulation, and extraction is necessary for consistent outcomes. Tablets are more stable and bioavailable than syrups. Higher doses (≥1200 mg/day) and effective extraction improve Echinacea’s clinical utility, particularly for pediatric respiratory support.

While Echinacea has been widely investigated for its potential benefits in respiratory infections across different age groups, the evidence in pediatric populations reveals notable distinctions from benefits in adults. The systematic review by David and Cunningham, which focused exclusively on adults, reported a modest reduction in the incidence of upper RTIs (risk ratio = 0.78) but found no clinically meaningful effects on the duration or severity of symptoms.[4] In contrast, our systematic review of pediatric studies demonstrates a more substantial impact, with reductions in infection episodes ranging from 32.5% to 55% and a 76.3% decrease in antibiotic prescriptions, particularly when Echinacea is administered at higher doses as a preventive measure. These differences may be attributed to age-related variability in immune system maturation, with children potentially benefiting more from the immunomodulatory properties of Echinacea than adults. Despite these contrasting findings, both reviews acknowledge significant methodological challenges. David and Cunningham identified considerable heterogeneity in Echinacea formulations, extraction methods, and dosing regimens as key limitations, a concern mirrored in our pediatric review, in which tablet-based preparations such as Echinaforce® Junior were found to yield more consistent outcomes than syrup formulations.[4] Importantly, while David and Cunningham did not assess reductions in antibiotic use – a critical outcome in pediatric care – our findings highlight Echinacea’s potential to not only prevent infections but also to reduce unnecessary antibiotic prescriptions, and thus address a major public health priority in the context of AMR.

Ultimately, these observations underline the fact that the therapeutic effects of Echinacea are context dependent and are shaped by factors such as age, formulation, and dosing. This underscores the need for age-stratified clinical guidelines and standardized protocols to optimize the use of Echinacea in respiratory health.

Echinacea is generally safe for children, for most studies report only such mild side effects as gastrointestinal discomfort, skin irritation, or allergy. Taylor et al., found no significant difference in overall adverse events compared to placebo, though rash was more common (7.1%) with Echinacea.[8] Consistent with this, Weber et al., also observed a higher rate of rash in the Echinacea group, but no increase in serious adverse events.[14]

Similarly, a study by Weishaupt et al., that evaluated doses of 1200 mg/day and 2000 mg/day reported that 96% of physicians rated Echinacea as well tolerated, with only mild side effects like gastrointestinal discomfort and headaches.[13] Ogal et al., found that Echinacea was associated with fewer adverse events in children and no serious side effects.[3] While generally safe, caution is warranted for children with allergies, and more extensive, long-term studies are needed to clarify hypersensitivity risks. Standardization of formulations, dosing, and extraction processes is essential to ensure consistent safety and efficacy. Current evidence supports Echinacea as a safe alternative for pediatric respiratory infections when standardized preparations are used and appropriate monitoring is done.

Research into Echinacea’s role in treating acute cough and upper RTIs in children has yielded promising results, and multiple RCTs have demonstrated reductions in infection rates, symptom improvement, and decreased antibiotic use. Ogal et al., reported significant declines in RTIs and viral load, probably attributable to immune modulation.[3] Similarly, Weber et al., found that the use of Echinacea was associated with a lower risk of subsequent infections and a longer median interval before recurrence.[14] This supports Echinacea’s role in enhancing immune defenses against respiratory infections in children in underserved communities. However, some claimed benefits lack a clear explanation, and multiple studies report limited or no effectiveness in relieving active symptoms. Taylor et al., reported that there was no significant difference from the placebo in the duration of the illness, thus questioning Echinacea’s role in treating active respiratory infections rather than in prevention.[8] Variability in trial outcomes is often attributed to differences in formulation, dosage, and extraction techniques, underscoring the need for standardized clinical protocols. In addition, while Echinacea is generally considered safe, Taylor et al., reported an increased risk of rash in children, suggesting that potential allergic reactions should be borne in mind when recommending Echinacea for pediatric use.[8] Based on that claim, further high-precision studies are critical to enhance Echinacea’s position within Evidence-based medicine and ensure that optimal clinical efficacy with minimal risks is achieved.

Conclusion

This systematic review emphasizes the possible advantages of Echinacea in the management of acute cough and RTIs in children. E. purpurea has been shown to decrease the frequency and severity of respiratory infections, lower viral load, and reduce symptoms, which positions it as a possible natural treatment for pediatric immune deficiency. Furthermore, its use has been correlated with reduced prescriptions of antibiotics, which indicates possible mitigation of AMR from unnecessary antibiotic treatment of viral infections. In contrast to lower doses, higher doses of Echinacea appear to provide greater relief from symptoms, although some investigations reported no apparent differences in the duration of symptoms, suggesting that Echinacea is better employed as a prophylactic rather than for active treatment of expressed symptoms. The safety of Echinacea was generally good apart from mild side effects of skin rash and gastrointestinal discomfort, which were commonly reported. However, differences in outcome of studies were caused by variations in formulations and dosages or methods of extraction, hence the need for standardized dosing and clinical protocol to guarantee consistent positive outcomes in pediatric practice.

Recommendations

To optimize Echinacea’s therapeutic potential in children’s respiratory health, the development of systematic clinical guidelines on dosing and form formulation is required. It is felt that Echinacea is most useful as a preventive measure during peak seasons of respiratory infection. However, the course of Echinacea should be carefully considered in children who have known allergies to plants on account of the risk of adverse allergic reactions to it. In light of its potential to decrease the use of antibiotics in viral infections, Echinacea can be considered as part of wider pediatric care strategies aimed at controlling AMR. For a medication to be designed for long-term use in children, it must be safe and effective, extraction techniques and dosage improved, and duration of use specified.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.