Background: Acute asthma exacerbations are a leading cause of emergency department (ED) visits and hospital admissions in children. Recurrent episodes contribute to morbidity and healthcare burden and predict long-term impairment. Identifying risk factors for ED revisits and hospital admissions is essential to improve prevention and management. Methods: This systematic review followed PRISMA guidelines. MEDLINE, Embase, CINAHL, and PsycINFO were searched from inception to the final search date without language restrictions. Eligible studies included children and adolescents with physician-diagnosed asthma presenting with acute exacerbations and reporting outcomes of ED revisit or hospital admission. Data extraction and study selection were performed independently in duplicate. Results: Eight studies were included, including pediatric populations from the United States, Italy, Egypt, Saudi Arabia, and the United Kingdom, alongside adult comparator cohorts. Risk factors for ED revisits and admissions included younger age, female sex, minority ethnicity, socioeconomic deprivation, excessive short-acting β2-agonist use, poor adherence to controller therapy, environmental exposures (tobacco smoke, allergens, irritants), comorbidities such as obesity and depression, and seasonal variation. System-level contributors included inadequate discharge prescribing (low corticosteroid use), high absconding rates, and poor follow-up. Infection was the most common precipitant in pediatric cases. Despite most ED visits resulting in safe discharge, a substantial proportion of children experienced revisits or required admission, with 41% of children in one cohort returning within 12 months. Conclusions: Pediatric asthma exacerbations leading to ED revisits or admissions are driven by a combination of demographic, clinical, environmental, and system level factors. Many of these determinants, medication adherence, controller therapy uses, exposure reduction, and follow-up, are modifiable. Addressing these factors through integrated, context-specific interventions is crucial to reducing recurrent acute care utilization in children with asthma.