Nasolacrimal duct obstruction (NLDO) is common in the pediatric population and presents as persistent epiphora, recurrent conjunctivitis, crusting of the eyelids, and occasionally dacryocystits. It is typically congenital and occurs at the level of the valve of Hasner. Treatment options for pediatric NLDO include non-surgical and surgical procedures. Treatment may be carried out either in-office or in the operating room. In this review, we discuss the pathogenesis of pediatric NLDO and provide an update on current treatment options, including medical management with massage, which remains highly successful, and surgery, which may be warranted in children over the age of 3 years, those with anatomic variations and craniofacial anomalies, patients unresponsive to medical therapy and probing, and patients with acquired NLDO. In addition, we explore the benefits of new technologies and endoscopic approaches, including shorter operative time and no scarring, as well as the ability to perform bilateral procedures and simultaneously address any additional intranasal pathology.