IMPORTANCE: There is a perceived increase in the number of microdirect laryngoscopies and bronchoscopies (MLBs) required on premature infants, infants with syndromic conditions, and those with complex congenital heart defects. Determining which neonates with certain underlying conditions require more aggressive interventions like tracheostomy, intubation, or supraglottoplasty might be useful for future preoperative planning and counseling of the families of newborns with complex medical conditions involving the airway. OBJECTIVES: To evaluate features and findings in neonates undergoing MLB in the first 28 days of life over a 10-year period and compare these findings with past publications. DESIGN, SETTING, AND PARTICIPANTS: Retrospective case series of 162 consecutive patients 28 days or younger undergoing MLB between January 1, 2002, and December 31, 2012, at a tertiary care children's hospital. INTERVENTION: Microdirect laryngoscopy and bronchoscopy. MAIN OUTCOMES AND MEASURES: Frequencies of common indications and findings in neonates undergoing MLB. To determine if findings on MLB had significant associations with gestational age, neonates with cardiac defects or syndromic conditions, and neonates who had at least 1 other comorbid condition, chi2 and Fisher exact tests were performed. Similar associations were analyzed between neonates with other comorbid conditions and need for interventions such as supraglottoplasty, tracheostomy, and intubation. RESULTS: Of the 162 patients, 101 were male (55.5%). The mean age at their procedure was 14.1 days. The mean weight of patients at MLB was 3.31 kg, and 32 (17.6%) were premature. Congenital conditions were noted in 114 patients (62.6%), and of these, 55 (30.2%) had congenital cardiac disease and 30 (16.4%) had syndromic conditions. Common indications for surgery were respiratory distress (n = 145 [79.7%]), stridor (n = 102 [56.0%]), and cyanosis or an acute life-threatening event (n = 67 [36.8%]). The most common findings at the time of surgery were laryngomalacia (n = 71 [39.0%]), subglottic stenosis (n = 58 [31.9%]), and tracheomalacia (n = 47 [25.8%]). Seventeen neonates (9.3%) required a tracheostomy, and 11 (6.0%) required a supraglottoplasty. Neonates with congenital heart defects were statistically significantly more likely to require long-term intubation (n = 9 [16.4%]; P = .03). Those with syndromic conditions were more likely to require long-term intubation and tracheostomy (n = 7 [23.3%] [P = .004] and n = 7 [23.3%] [P = .01], respectively). Premature infants who required MLB had a decreased incidence of laryngomalacia (n = 7 [21.9%]; P = .03), and those with comorbid conditions, an increased incidence (n = 43 [33.3%]; P = .01). There was minimal morbidity directly associated with the procedure. CONCLUSIONS AND RELEVANCE: Neonates undergoing MLB most commonly presented with respiratory distress and stridor and were most commonly found to have laryngomalacia and subglottic stenosis. More than half of the patients studied had other comorbid conditions. Those with cardiac defects and syndromic conditions were more likely to require intubation, and those with syndromic conditions were more likely to eventually undergo tracheostomy.