We retrospectively reviewed the charts of seven neonates and infants with severe micrognathia and upper airway obstruction who underwent mandibular distraction osteogenesis as an alternative to long-term tracheostomy at the Children's Hospital at Westmead, Sydney, from 2004 to 2007. All patients required a variety of airway interventions at an early age and had poor feeding or failure to thrive. These children had other anomalies and required many investigations and procedures and presented repeated airway challenges for the anaesthetist. The mean number of anaesthetics per child in this series was 6.7 (range 4 to 13). Under anaesthesia, four patients had grade 4 laryngoscopy, one was grade 3 but two were only grade 2. Patients with a preoperative grade 4 laryngoscopy were very likely to need fibreoptic endotracheal intubation. Duration of intubation after surgery for mandibular distraction was a mean of 8.17 days (range 1 to 19). Three were extubated in the operating theatre and three in intensive care. Five patients had an improved laryngoscopy grade after completion of mandibular distraction and one remained grade four The remaining patient had a tracheostomy from birth.