For over 20 yr, antireflux surgery has been the treatment of choice for severe gastroesophageal (GE) reflux disease in children, and antireflux operations are said to be the commonest major surgical procedures performed by pediatric surgeons in North America. Yet, only recently have the results of surgery been more closely examined; both the surgical morbidity and operative failure rates have been found to be particularly high in children with neurological impairment, repaired esophageal atresia, and chronic lung disease. Of interest, these groups of children are among those most at risk for developing severe GE reflux disease in the first place. Close examination of surgical reports also raises some questions about the indications for surgery in some children, specifically whether the presence of severe GE reflux disease had been established before surgery and whether a trial of appropriate medical management had been given. Failure of medical management has always been an accepted indication for surgery. However, in the past the medical management that was available for children was ineffective because drug dosages were not optimized (H2-receptor antagonists), the drugs had side effects precluding their use long term or in high doses (bethanechol, metoclopramide), or they were simply insufficiently potent to treat severe GE reflux disease (all the above drugs plus cisapride). Thus, in the past, failure of medical management did not mean failure of very much. In contrast, the proton pump inhibitor omeprazole has recently been shown to be effective and safe for the treatment of severe childhood GE reflux disease refractory to other medical treatments and where antireflux surgery has failed. The issues of why certain groups of children are at highest risk for severe GE reflux disease are discussed as are the outcomes and roles of surgical and medical treatment for all groups of children with severe GE reflux disease. The options of antireflux surgery or omeprazole should be reserved for those children with severe GE reflux disease, e.g., GE reflux accompanied by a complication.