OBJECTIVE Almost one-half of all pediatric gastrostomy tube insertions are accompanied by a fundoplication, yet little is understood about the surgical decision-making for these procedures. The objective of this study was to examine the decision-making process of surgeons about whether to perform a fundoplication in children already scheduled to have a gastrostomy tube placed. METHODS A written questionnaire of all pediatric surgeons at a major children's hospital was completed for each planned gastrostomy procedure over the course of 1 year; the questionnaire asked about various influences on the fundoplication decision: primary care and subspecialty physicians' opinions, patient characteristics, and parent opinions. Patient demographics and clinical characteristics from the medical record, as well as questionnaire responses, were summarized for each gastrostomy occurrence. We modeled the association of questionnaire responses and patient characteristics with the outcome of having a fundoplication. RESULTS We received questionnaires on 161 of 169 eligible patients (95%). A total of 52% of patients had fundoplication. Primary care physicians were involved in 44% of decisions, and when involved had "a lot" of influence on the fundoplication decision only 28% of time, compared with neonatologists (61%), hospitalists (44%), pediatric pulmonologists (42%), and pediatric gastroenterologists (40%). A total of 86% of patients had a subspecialist involved, and 28% had >1 subspecialist. A pH probe was performed in 7.5% of cases, and failed pharmacotherapy was noted by the surgeons in only 26.5% of the fundoplications performed. CONCLUSIONS The decision to do a fundoplication was rarely based on definitive testing or failed medical treatment. From the surgeon's perspective, subspecialists were more influential than primary care physicians, which is at odds with current concepts of the medical home.