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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.