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Importance The role of intravenous aminophylline in acute asthma in childhood is unclear.Objectives To assess the safety and efficacy of intravenous aminophylline for asthma in children.Methods From 1966 to May 2024, we searched MEDLINE, Embase, CINAHL, Web of Science and the Cochrane Central Register of Controlled Trials. We included only randomised controlled trials testing standard treatment in combination with aminophylline and followed the international guidelines for conducting systematic reviews. The outcomes measured were morbidity, escalation of care, length of hospital stay, adverse events, mortality and lung functions. We used the random-effects model for data analysis and the fixed-effects model to evaluate heterogeneity.Results Nine studies (466 participants) fulfilled our a priori eligibility criteria. No significant difference was found in post-treatment asthma severity score (mean difference (MD)=0.13, 95% CI −0.79 to 1.06, I 2=0 %), hospitalisation rate (risk ratio (RR)=0.66, 95% CI 0.27 to 1.59, I2=0%), paediatric intensive care unit admission (RR=0.73, 95% CI 0.51 to 1.05, I2=0%), intubation rate (RR=0.09, 95% CI 0.01 to 1.64, p=0.1) or length of hospital stay (MD=−3.62, 95% CI −13.05 to 5.82, I2=31%). Emesis (RR=3.52, 95% CI 2.04 to 6.06, I2=0%) and nausea (RR=4.92, 95% CI 2.41 to 10.06, I2=0%) occurred more in the aminophylline group. One study showed improved lung function in the aminophylline group, while others showed no difference.Conclusion This review showed limited evidence of the benefit of intravenous aminophylline in managing asthma in most preventilation severity parameters. However, lowering the intubation rate and improving lung function deserve more attention.PROSPERO registration number CRD42023405234.