Caudal Epidural analgesia reduces the overall intraoperative Anesthetic requirement and facilitates rapid return of conscious state with stable hemodynamic condition. Different additives like, opioids, ketamine and clonidine have shown better pain management but brought about evitable complications. Addition of neostigmine improves pain management with minor postoperative complications. The purpose of this review was to compare caudal epidural neostigmine co-administered with bupivacaine and Bupivacaine alone. Different databases were explored to identify controlled clinical trials comparing neostigmine co-administered with bupivacaine and bupivacaine alone. Seventeen controlled trails have been collected for eligibility assessment and eleven trials were incorporated for extraction of outcomes. Eleven studies (838 participants) were included in this review. The mean difference of Postoperative analgesic duration was better in patients received neostigmine co-administered with bupivacaine when compared to bupivacaine alone (MD=3.29, 95% confidence interval (CI) 2.86 to 4.4, 4 trials, 193participants). There was significant association on postoperative analgesic consumption in 24 h when neostigmine group was compared with bupivacaine alone (SMD=-1.57, 95% confidence interval (CI) -2.14, 1.01, one trial, 63 participants). Conclusion: Caudal epidural with neostigmine co-administered with bupivacaine is better as compared to caudal epidural with bupivacaine.