BACKGROUND: The pediatric flat foot frequently presents as a common parental concern in the health care setting. Foot orthoses are often used, yet benefits are uncertain and disputed, having been variably investigated. A recent Cochrane review cites limited evidence for nonsurgical interventions. This critical and structured review evaluates the effect of pediatric foot orthoses from assessment of the current literature. METHODS: A systematic search of the following electronic databases: Medline, CINAHL, AMED, and SPORTDiscus, using an array of search terms. A further search was also performed on relevant reference listings. Inclusion criteria were peer-reviewed journal articles, publication date from 1970 onwards, in the English language. Exclusion criteria were surgery interventions, adult subjects, rigid flat foot, articles based on opinion. A structured Quality Index was used to evaluate the research quality of articles. Three reviewers independently assessed the studies with disputes resolved by majority consensus. Studies were then grouped according to the outcome measures used. RESULTS: Thirteen articles, from an initial 429, met the criteria for quality evaluation. The mean Quality Index score was 35% (range: 13% to 81%), indicative of generally poor and varying methodological quality. CONCLUSIONS: The low quality of the studies negates definitive conclusions. Only 3/13 quality evaluations scored > 50%; hence, evidence for efficacy of nonsurgical interventions for flexible pediatric flat feet is very limited. Future research needs validated foot type assessment, applicable outcome measures for the intervention, the use of control groups, allowance for independent effects of footwear, age range comparisons, larger samples, and prospective, longer follow-up. CLINICAL RELEVANCE: There is very limited evidence for the efficacy of nonsurgical interventions for children with flexible flat feet. Clinicians need to consider the lack of good-quality evidence in their decision-making for the management of pediatric flat foot.