Fluoride exposure through drinking water is a public health concern due to its potential neurotoxic effects, particularly in children. Evidence from Indian populations remains fragmented and inconclusive. This study systematically reviewed and synthesized evidence on the association between fluoride exposure and cognitive development in Indian children. A comprehensive search of PubMed, Embase, Web of Science, Scopus, PsycINFO, and Google Scholar was conducted up to July 2025. Observational studies from India evaluating the relationship between fluoride exposure through drinking water and cognitive outcomes in children aged 0�18 years were included. Eleven studies with over 6000 participants were analyzed. Children exposed to fluoride concentrations greater than 2.0 ppm showed significantly lower intelligence quotient (IQ) scores, with a pooled effect size of �6.5 IQ points (95 confidence interval: �7.3 to �5.7). Subgroup analyses indicated greater susceptibility in children aged 6�10 years. The evidence revealed substantial heterogeneity and some publication bias. Limitations included the predominance of cross� sectional study designs and variability in exposure measurement and cognitive assessments. Elevated fluoride exposure is associated with reduced cognitive performance in Indian children. Regional defluoridation strategies and further longitudinal research are urgently warranted. Systematic Review Registration: PROSPERO ID: CRD42023454735. © 2025 Elsevier B.V., All rights reserved.