BACKGROUND: Adhesive small bowel obstruction (ASBO) develops in ~5% of children and adolescents after major abdominal surgery. The aims of this study were to: 1) describe the current use of operative management in children and adolescents with ASBO and 2) investigate the association between operative delay and the rate of small bowel resection. STUDY DESIGN: All patients 2 to 20 years of age admitted with ASBO in the 2003 and 2006 Kids' Inpatient Database (KID) were identified. Rates of operative intervention were described, and factors associated with small bowel resection were analyzed in a logistic regression model. RESULTS: Of 2,089 patients admitted with ASBO, 1,786 (85.5%) underwent operative intervention with lysis of adhesions (LOA; n = 1,493; 83.6%) or small bowel resection (SBR; n = 293; 16.4%). Factors associated with the use of operative intervention in univariate analysis included younger age (p < 0.001), race (p = 0.034), and management at a children's hospital (p < 0.001). The time from admission until operation (mean +/- SD) was significantly longer in patients who underwent SBR (2.1 +/- 2.6 days) compared with LOA (1.5 +/- 2.0 days; p < 0.001). Compared with patients who underwent surgery within the first day after admission, the adjusted odds of SBR were similar on the second day after admission (odds ratio [OR] 1.40, 95% confidence interval [CI] 0.94 to 2.09) but increased when surgery was performed on days 3-14 (OR 1.67, 95% CI 1.19 to 2.34). CONCLUSIONS: The majority of children and adolescents admitted with ASBO currently undergo operative management, and 16.4% of these patients receive small bowel resections. Operative intervention should be considered in patients who do not exhibit signs of improvement by the second day after admission to avoid potentially increasing the risk for bowel loss.