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Background and Aims Caudal epidural block is commonly used in pediatric infraumbilical surgeries for postoperative analgesia. While fentanyl is traditionally employed as an adjuvant to prolong local anesthetic effect, dexmedetomidine has emerged as a promising alternative due to its analgesic and sedative properties with a potentially more favorable safety profile. Objective: To compare the efficacy and safety of dexmedetomidine versus fentanyl as adjuvants to bupivacaine in pediatric caudal blocks.Methods performed a systematic review and meta-analysis in accordance with PRISMA guidelines. Databases searched included PubMed, Embase, and Cochrane Library through May 2025. We included randomized controlled trials comparing dexmedetomidine and fentanyl as adjuvants in children undergoing caudal blocks with bupivacaine. Primary outcomes were duration of analgesia, rescue analgesia requirement, postoperative sedation, and adverse effects. Risk of bias was assessed using Cochrane RoB 2. Meta-analysis was performed using RevMan 5.4, applying a random-effects model.Results Six randomized trials (n ≈ 340 children, ASA I–II, aged 1–12 years) were included. Dexmedetomidine significantly prolonged analgesia compared to fentanyl (mean difference ≈ +85 minutes; p < 0.001; I 2 ≈ 45%) and reduced the need for rescue analgesia (RR ≈ 0.25; 95% CI 0.10–0.62; I2 = 0%). FLACC pain scores were consistently lower in the dexmedetomidine group. Although postoperative sedation was more pronounced with dexmedetomidine, no significant differences in bradycardia or hypotension were observed. Incidence of nausea, vomiting, and pruritus was significantly lower with dexmedetomidine (RR ≈ 0.3 and 0.2, respectively).Conclusions Dexmedetomidine is associated with longer postoperative analgesia and fewer opioid-related side effects than fentanyl when used as a caudal adjuvant in children. While increased sedation warrants close monitoring, dexmedetomidine appears to be a safer and more effective alternative, supporting its use in routine pediatric anesthesia practice.