Purpose: The optimal management of achalasia in children and adolescents remains unclear. The aim of this study was to review a single institution's experience with endoscopic and surgical interventions in children with achalasia. Methods: A retrospective review was conducted of the medical records of children treated for achalasia from 1978 to 2008. Patient demographics and interventions were reviewed. Outcomes after procedural intervention were evaluated. Results: Thirty-five patients with achalasia were identified, and data were available for 34 (age, 13 ± 6 years; male, 62%). Eighteen patients underwent esophageal dilation (ED), and 16 patients underwent Heller myotomy (HM). Follow-up was available for 30 patients (ED, 15; HM, 15). There was symptom recurrence in 15 of 15 ED cases and 8 (53%) of 15 HM cases (P < .01). Additional interventions were performed in 14 (93%) of 15 ED cases and 6 (40%) of 15 HM cases (P < .01). Conclusions: Heller myotomy may provide more durable long-term outcomes, as defined by symptom recurrence and need for subsequent intervention, and may be considered the procedure of choice. © 2010 Elsevier Inc. All rights reserved.