The chest X-ray is the most valuable imaging modality in the assessment of the neonate with respiratory distress. Whilst many of the radiological appearances are relatively non-specific, integration of the clinical features with the X-ray appearances will help the clinician arrive at the correct diagnosis in most cases. In a minority of infants, particularly those with a congenital malformation of the chest or airways other imaging modalities may be required. This paper will describe the radiological appearances of the most important causes of neonatal respiratory distress and highlight those situations where more complex investigations are necessary.