Echinacea Benefits and Safety in Pregnancy & Breastfeeding

Echinacea is among the most commonly used herbs in pregnancy and breastfeeding. It has a rich history of traditional use as an immune tonic. Often recommended by midwives and herbalists but cautioned against by doctors, women are left confused about its safety. Read on to uncover the complete evidence and decide for yourself.

Disclaimer: This post is for informational purposes only. None of the information here should be taken as medical advice. Even if a remedy is classified as safe in Herbal Doula blog posts based on the existing evidence, that doesn’t mean it’s safe for you. The classifications in the database are just a general reference point. Follow your body, keep track of your response, and consult an herbalist, holistic practitioner, traditional midwife, or anyone else you feel may help you if you need expert advice. 

Echinacea Safety Categorization

Pregnancy Safety:

Safe

Labor Safety:

Unknown

Breastfeeding Safety:

Safe

Echinacea is likely safe to use during pregnancy, based on limited human and animal studies, clinical experience, and a long history of traditional use. Safe use involves taking echinacea at the recommended doses and intervals, self-monitoring potential reactions or side effects, and consulting a knowledgeable care provider with any questions (midwife/herbalist/MD/ND).

The use of echinacea during breastfeeding may be safe during breastfeeding based on clinical, anecdotal, and traditional data. Human studies are lacking, so some caution and/or supervision by an experienced care provider is recommended.

Allergic reactions are possible. People with a history of allergic reactions to other members of the daisy family should use echinacea with caution or avoid it.

Drug interactions are possible. If you are taking OTC or prescription medications, consult a healthcare provider before use to avoid drug-herb interactions.

The safety of echinacea in labor is unknown. Given that this herb is likely safe throughout the pregnancy and breastfeeding continuum, there is no reason to suggest it may be harmful during labor. However, data to confirm this are currently lacking.

Echinacea Use during Pregnancy & Breastfeeding

Echinacea is among the most widely used herbal medicines during pregnancy and breastfeeding in Western countries.

Women use echinacea to support immune health and to help fight colds, respiratory infections, urinary tract infections (UTIs), mastitis, and encourage wound healing. 

Also, echinacea products are among the most popular herbal medicines on the North American market among the general population. All the while, over half of all pregnancies are unplanned, according to some estimates. Plus, some women may find out that they’re pregnant well into the first or even second trimester. This means that many women inadvertently use echinacea in their first trimester.

Sadly, many health care practitioners warn women against using echinacea in pregnancy and while breastfeeding. Such advice is given despite a solid amount of echinacea safety research that surpasses the evidence on the safety of many other routinely used drugs and interventions (including ultrasounds, OTC medications, antibiotics, and others).

Summary of Purported Echinacea Benefits

Echinacea is a wildflower native to North America with a long history of traditional indigenous use for various purposes. Originally from the area east of the Rocky Mountains in the United States, echinacea is now cultivated widely.

It’s also known as purple coneflower and American coneflower.

Today, three species of the genus Echinacea are medicinally used: Echinacea purpurea, Echinacea angustifolia, and Echinacea pallida. Echinacea species are used in a large variety of echinacea products in Europe and North America for preventing and helping fight the common cold, flu, and upper respiratory tract infections (Heitman et al., 2016).

Echinacea has also been traditionally and anecdotally used for:

• Urinary tract infections (UTIs), other bacterial and viral infections, and as an immune tonic
• Vaginal inflammation (including bacterial vaginosis/BV and vulvovaginitis)
• Other inflammatory conditions (including endometriosis and cervical inflammation)
• Skin boils, acne, and other types of skin irritation 
• Mastitis 
• Wound healing 
• Painful menstruation 

In many of the conditions listed above, echinacea is combined with other herbs and treatments.

Clinical studies on the effectiveness of echinacea for these indications are lacking.

Different parts of the plant and methods of extraction can be used, sometimes making clinical research and comparisons difficult.

A Cochrane review from 2014 that included over 4600 patients enrolled in 24 randomized controlled trials comparing echinacea with placebo found weak evidence in favor of echinacea products being associated with a small reduction in cold incidence (Karsch‐Völk et al., 2014).

Echinacea is rich in active compounds that help balance the immune system (polysaccharides and glycoproteins) and boost antioxidant defense (caffeic acid derivatives and alkamides) (Woelkart & Bauer, 2016).

Research on Echinacea While Pregnant & Breastfeeding

The next part is for people who like to dig deep into the research like me. The most important findings are bolded if you want to understand the bottom line.

Safety classification from other associations

Some associations consider the use of echinacea during pregnancy and breastfeeding likely safe, while others caution against its use until more human data is available.

The Therapeutic Research Center Natural Medicines database classifies echinacea as possibly safe during pregnancy when used by mouth and for up to 7 days, based on preliminary evidence. They note insufficient reliable information about its safety in breastfeeding.

Many traditional herbal medicine classifications consider echinacea a Category A medicine in pregnancy with no documented risk to the fetus (Romm, 2017).

Mill and Bone in their “Essential Guide to Herbal Safety” classify echinacea as having:

• Minimal risk in pregnancy based on a high level of evidence 1b: “Strong scientific evidence; Statistically significant evidence from one or more cohort studies or control studies.”
• Minimal risk in breastfeeding based on a low level of evidence 4: “Theoretical evidence; Evidence based on scientific theory or expert opinion”

On the other hand, the European Medicines Agency concludes that the safety of echinacea during pregnancy has not been established.

The German Commission E Monographs state that no restrictions on use during pregnancy or lactation are known except for parenteral (IV) use of Echinacea purpurea root, but no references to scientific papers are given.

2006 Canadian review

A 2006 review published in the Canadian Journal of Clinical Pharmacology concluded that echinacea is likely safe during pregnancy and breastfeeding systematically compiling data from 7 electronic databases according to the grade of evidence (Perri et al., 2006).

Specifically, the authors discovered:

• Good scientific evidence from a prospective cohort study that taking echinacea by mouth during the first trimester does not increase the risk for major malformations (i.e. echinacea is non-teratogenic)
• Low-level evidence based on expert opinion that taking echinacea by mouth at the recommended doses is safe for use during pregnancy and lactation

They add that more high-quality human studies should determine the safety of echinacea during breastfeeding.

When it comes to different formulations, 58% of women used capsules or tablets, while 38% used tinctures. The dosage of capsules/tablets varied from 250 to 1000 mg/day. Tincture dose varied from 5 to 30 drops per day. Duration of use also varied but was normally continuous for 5 to 7 days (Perri et al., 2006).

Also, 54% of women reported taking the herb in the first trimester and 8% used Echinacea throughout pregnancy.

One limitation of the study is that the participants used a range of different preparations of Echinacea at different dosage regimens, but this also makes their findings more relevant to real-world use.

Motherisk Program and the famous 2000 study

A commonly cited study about the safety of Echinacea was conducted by Motherisk back in 2000 (Gallo et al., 2000).

Before I go into the study details, I think it’s important to understand the story behind the Motherisk program so we know where the data is coming from.

Motherisk was a clinical and research program meant to provide evidence-based safety information on exposures to drugs and supplements in pregnancy and lactation. It was established at The Hospital for Sick Children in Toronto, Ontario, Canada in 1985 as a teratogen information service.

Motherisk used to receive about 200 calls per day, 20% from health care providers and 80% from pregnant or breastfeeding women or their family members (Glauser, 2009).

This program has since been through several scandals that challenged its reliability and accountability and was finally shut down in 2019. Among other allegations, Motherrisk was accused of providing biased information about the effectiveness or safety of some medications and not disclosing funding from pharmaceutical companies (Glauser, 2009).

Back to the study…

Researchers followed up with women after contacting the Motherisk Program regarding the use of echinacea in pregnancy. A total of 206 women who used echinacea in pregnancy were enrolled, of which 112 women used the herb in the first trimester. Echinacea users were matched to 206 women not exposed to teratogenic agents (the control group). Rates of birth defects and complications between the groups were compared  (Gallo et al., 2000).

The researchers didn’t find a statistical difference between women who used echinacea and those who didn’t in pregnancy outcomes (live birth, spontaneous abortion, therapeutic abortion), delivery method, maternal weight gain, gestational age, birth weight, fetal distress, or major malformations.

The Motherisk group concluded that the use of echinacea during pregnancy—especially during the first trimester when organogenesis takes place—is not associated with an increased risk of major malformations.

The main study author, toxicologist Gallo, said for WebMD:

“It’s still really up to mum to decide how comfortable she feels with this level of information. We cannot without question say [echinacea is] safe. What we’re saying is, based on the published data and how this herb has been used historically over the last several years, we have not seen any reason to suggest that it’s harmful.”

Norwegian studies (2011, 2014, and 2016)

The first study interviewed 600 women at a University Hospital in Norway after birth about their use of conventional and herbal medicines during pregnancy. About 40% of the women reported having used herbs drugs during pregnancy and 7.5% used echinacea. Also, a concerning 86.3% of women reported having used conventional drugs during pregnancy (Nordeng et al., 2011).

No association was found between echinacea use during pregnancy and adverse outcomes in this study.

A 2014 Norwegian review searching various databases identified small human studies and two small animal studies of the safety of echinacea in pregnancy. Although no adverse outcomes were noted in any study, this research team concluded that there’s insufficient evidence to recommend echinacea to pregnant women (Holst et al., 2014).

In the latest and largest Norwegian study, 363 (0.5 %) out of  68,522 women reported the use of echinacea during pregnancy via questionnaires (weeks 17 and 30). They compared their answers to information on pregnancy outcomes in relation to echinacea use in pregnancy. Echinacea users were older and less likely to be smokers. This was the largest study to date investigating the safety of echinacea in pregnancy, and the results are reassuring (Heitman et al., 2016).

The researchers found that the use of echinacea during pregnancy doesn’t seem to increase the possibility of malformations or negative pregnancy outcomes such as preterm birth, low birth weight, or small for gestational age.

To sum it up, the use of echinacea during pregnancy was not associated with an increased risk of malformations or adverse pregnancy outcomes. 

Other reviews

One of the most comprehensive multinational, cross-sectional studies to classify the safety of herbal medicines in pregnancy labeled echinacea as safe (Kennedy et al., 2016).

An Austrian review from 2016 explains that pregnancy is not a contraindication for Echinacea but that supervision by a care provider during use would be beneficial (Ardjomand-Woelkart & Bauer, 2016).

The authors point out that echinacea preparations are generally well-tolerated and cite already mentioned studies that found no association between echinacea use and adverse pregnancy or fetal outcomes. A 2019 review came to similar conclusions (Ardjomand-Woelkart & Bauer, 2016; Balbontín et al., 2019).

Animal and cellular studies

Preclinical data indicate that Echinacea purpurea roots and aerial parts are unlikely to cause negative reproductive or developmental effects in laboratory animals (Mengs et al., 1991)

Oral doses of up to 2700 mg/kg of liquid echinacea extract did not cause embryotoxicity in rats or rabbits or affect postnatal development in rats. No evidence of harm was noted in studies investigating gene mutations, malignant transformation, chromosome aberrations in bacteria, mouse lymphoma cells, cultured hamster cells, or human lymphocytes (Mengs et al., 1991)

According to one study on cells and tissues, echinacea’s antibacterial and anti-inflammatory properties and a long history of safe use may hold promise for reducing inflammation in the cervix that can lead to premature labor. Cervical inflammation can, in some cases, lead to premature labor and the current treatments are either unsafe or ineffective (Estes, 2013).

The study discovered that echinacea lowers levels of inflammatory factors (activated master inflammation transcription factor, nuclear factor kappa B, and the expression of pro-inflammatory cytokines) associated with inflammation-induced preterm labor.

The authors conclude that their promising findings warrant further research aiming to develop natural strategies for modulating infection-induced preterm labor.

Focus on Breastfeeding

Despite widespread anecdotal use, the scientific data about the safety and efficacy of echinacea during breastfeeding is sparse.

All in all, echinacea use under expert guidance at the recommended doses is not considered harmful while nursing. More human data about its safety would be helpful (Nice et al., 2001).

No known contraindications to its use during nursing exist other than allergy to the plant family Asteraceae, which is a general contraindication. There is limited evidence to suggest that compounds found in echinacea pass into breast milk and no evidence that echinacea alters breast milk supply in any way (Nice et al., 2001).

General Precautions & Interactions

Allergy warning

Echinacea species are members of the Asteraceae or daisy family. People who are sensitive to other members of the daisy family (including ragweed, chrysanthemums, marigolds, and sunflowers) may be at higher risk for allergic reactions to echinacea.

If you have a history of allergic reactions to this plant family and never used echinacea before, it may be best to avoid it in pregnancy.

Drug interactions list

Here is a list of possible interactions between echinacea and drugs*:

• Caffeine: (↑) Caution
• Drugs metabolized via cytochrome P450 1A2 (CYP1A2): (↑) Caution
• Drugs metabolized via cytochrome P450 3A4 (CYP3A4): (⇅) Caution
• Darunavir (anti-HIV medication): (⇅) Minor
• Etravirine (anti-HIV medication): (⇅) Minor
• Lopinavir/ritonavir (anti-HIV medication): (⇅) Minor
• Docetaxel (cancer drug): (⇅) Minor
• Etoposide (cancer drug): (↑) Caution
• Immunosuppressants: (↓) Caution
• Midazolam (sedative): (↑) Minor
• Warfarin (blood thinner): (↑) Minor

*Arrows indicate whether echinacea may increase (↑) or decrease (↓) the levels or effects of the drug. An up-down arrow (⇅) means that both effects are possible. This possible effect is based on findings from the scientific literature and has not been confirmed in clinical studies.

Interactions other than the ones listed here are theoretically possible.

Drug interactions research

Animal studies also caution about the following potential interactions (Ardjomand-Woelkart & Bauer, 2016):

• Melatonin: Detrimental effect on the levels of mature granulocytes in bone marrow and spleen when administered together but not when each supplement is given alone.
• Phenytoin (anticonvulsant medication): echinacea may reduce the teratogenic activity of phenytoin in mice.
• Warfarin (blood thinner): increased clearance of the drug but no INR changes

Echinacea Dosage & Formulations

The typically recommended dosage of echinacea is:

• Dry powdered extract: 900-1500 mg/day (as capsules or tablets)
• Liquid extract tinctures: 2-10 ml/day
• Tea: 3 cups/day, some sources recommend up to 6 cups on the first day
• Expressed juice (made by expressing the juice from the fresh herb): 6-9 ml/day

Some studies have reported using higher doses of the extract (up to 4000 mg daily), but their safety hasn’t been researched in pregnancy.

Expressed juice and tea can also be used on the skin for superficial wounds.

The European Medicines Agency mentions dosing echinacea tea as 1 g of the dried plant matter in 150 ml of boiling water (small cup/5oz), steeping for at least 10 minutes, and taking 3 times daily. This is on the lower dosage spectrum. Calculating the grams you’re making tea with can get a bit confusing (it depends on the plant), but 1 teaspoon of dried plant matter is usually around 1-1.5g (EMA monograph).

To make 1 big cup of echinacea tea:

1. Boil a large cup of water (about 10oz/300 ml)
2. Pour over 2 teaspoons of loose leaf tea (or twice as much of the fresh herb)*
3. Let steep for 10-15 minutes
4. Strain and enjoy!

*Echincea roots are typically used for tea and are better researched than the aerial parts (leaves and flowers).

You can make a larger quantity in the morning and then sip your tea throughout the day.

What Is the Bottom Line?

• Based on solid evidence, echinacea is likely safe to use during pregnancy at the recommended doses and in the short term
• A limited, low level of evidence suggests that echinacea may be safe to use during breastfeeding
• Echinacea is considered to be an immune tonic. It’s commonly used to help fight colds, respiratory infections, UTIs, and inflammatory conditions. Other uses include healing wounds and skin inflammation
• Caution is advised if you are allergic to plants of the daisy family or take prescription medications
• If unsure whether echinacea is right for you, consult an experienced provider.

>>>>>     Love herbs? Read the report on chamomile safety in pregnancy and breastfeeding.

Did you use echinacea during pregnancy or while breastfeeding?

Let me know about your experience in the comments and share this article if you found it useful!

<3

Ana