The epidemic of childhood obesity is associated with an increased incidence of cardiovascular risk factors, adult obesity, and obesity-related comorbidity. In this review article we highlight existing data on approaches to the management of childhood obesity. There are currently three main treatment modalities for childhood obesity: a) lifestyle modifications, which include exercise, diet, counseling, and combination of these, b) pharmacotherapy, which may have a role in a select group of overweight adolescents, and c) bariatric surgery. The three main drugs currently considered for treatment of pediatric obesity are orlistat, sibutramine and metformin. Only the first two are currently approved by the Food and Drug Administration (FDA) for the long-term treatment of obesity. Safety and efficacy have not been determined beyond 4 years for orlistat and 2 years for sibutramine. Bariatric surgery in pediatric patients with morbid obesity results in sustained and clinically significant weight loss but also has the potential for serious complications. Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric binding (LAGB) are the two main surgical procedures which have been used in pediatric obesity. RYGB is considered a safe and effective option for extremely obese adolescents as long as appropriate long-term follow-up is provided. LAGB has not been approved by FDA for use in adolescents, and therefore should be considered investigational. Finally, sleeve gastrectomy, another type of weight loss surgery, which has gained significant appreciation in adults, should be also considered investigational; existing data are not sufficient to recommend widespread and general use in adolescents.