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Background The role of inhaled/nebulised ipratropium bromide (IB) in asthma is unclear.Aims To assess the efficacy and safety of inhaled/nebulised IB for asthma management in children.Methods We searched MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of Controlled Trials and the Web of Science until July 2024. We included randomised controlled trials (RCTs) and followed international guidelines for reporting systematic reviews. Outcomes included morbidity, escalation of care, length of hospital stay, mortality, adverse events and lung function.Results We included 24 studies (total participants n=3238). The hospitalisation rate (risk ratio (RR) 0.84, 95% CI 0.70 to 1.00, I ² 30%), hospital stay in hours (MD 1.75, 95% CI −0.87 to 4.36, I² 15%) and paediatric intensive care (PICU) admission (RR 0.91, 95% CI 0.35 to 2.32, I² 0%) were similar. The hospitalisation rate was lower in patients who received IB nebuliser (RR 0.76, 95% CI 0.64 to 0.90, I² 0%).The asthma severity score was significantly better in the IB group (MD −0.38, 95% CI −0.63 to −0.12, I2 59%). No serious adverse events were reported.Conclusion This review found high-certainty evidence that the IB nebuliser leads to a lower hospitalisation rate. However, when inhaled/nebulised IBs were analysed together, the hospitalisation rate was similar, with moderate certainty evidence. IB improved asthma clinical scores, with low certainty evidence. No difference was reported in other prespecified outcomes.Considering the current evidence and safety profile, inhaled/nebulised IB needs to be considered as an additional treatment for acute asthma exacerbation.PROSPERO registration number CRD42023405023.