Abstract Background: Loss of postural balance in DS children results in deterioration of gait activities and daily living tasks, so it has a significant impact on quality of life. Many inter-ventions have been intended to improve balance in DS children. Aim of Study: The aim was to examine the effect of hippotherapy on postural balance in children with down syndrome. Subjects and Methods: Search was made on children with down syndrome aged from 2 to 18 years. Search was made in Pubmed, Pedro, Cochrane and goggle scholar web site up to date. Systematic review of randomized controlled trials, the intervention used was hippotherapy as a group programs four studies were selected according to inclusive and exclusive criteria. Results: Four articles were included in this review. Al-though the current level of evidence is weak, our synthesis found that children with down syndrome, Data were extracted independently using a modified standardized Excel template from American Academy for cerebral palsy and Developmental Medicine's (AACPDM), hippotherapy had a significant effect postural balance in children with down syndrome. Conclusion: The current literature on hippotherapy is limited. Large randomized controlled trials using specified protocols are needed to more conclusively determine the effects on children with down syndrome. From the current evidence, it appears that hippotherapy have positive effects on postural balance in children with down syndrome.