Purpose: Ventilatory obstructive apnea in the newborn is a challenging and controversial problem. Distraction osteogenesis has provided a powerful tool for treatment of mandibular hypoplasia in the neonate, yet little quantifiable evidence exists regarding its use, and furthermore, few parameters have been defined that guide its clinical use. We report our experience with 36 infants who underwent distraction osteogenesis (DO) for hypoplastic mandible (HM) and obstructive sleep (OSA) apnea using an internal device, and who underwent critical analysis of their obstruction through the use of multi-channel polysomnography (PSG). Methods: A retrospective chart review was performed of all patients with HM and OSA who were treated with a vertical ramus osteotomy and mandibular distraction osteogenesis as infants from 2004-2008. The criteria for selection of this technique were: 1) hypoplastic mandible; 2) obstructive sleep apnea by preoperative sleep study (or inability to extubate); 3) and age less than six months.  Vertical ramus osteotomies and coronoid resections were performed via bilateral Risdon incisions and internal titanium distraction devices were placed. After a four day latency phase, the patients underwent bilateral DO for 20 millimeters (mm) at a rate of 1 mm/day. Results: The 36 patients who underwent vertical ramus osteotomies for hypoplastic mandible with associated obstructive sleep apnea had appropriate follow up for postoperative evaluation. The mean distraction length was 18 mm with a range of 16-20 mm, and children were brought into edge-on occlusion or slightly overcorrected. Time allowed for consolidation was a minimum of two days per mm of distraction. Of these 36 patients, 34 (94%) showed complete improvement. Two patients required tracheostomy, one with a rigid chest from chondrodysplasia punctata and one with severe periventricular leukomalacia. Associated complications included: 4 infections (11%), one transient facial nerve paresis (3%). In all cases the mandibular dental midline remained true to the maxillary dental and facial midline. In no case has the mandible undergone compensatory overgrowth and the occlusal relationship is favorable in all cases. Twenty patients had both pre-operative and post-operative PSG’s available for review. The mean apnea-hypopnea index (AHI - #apneas and #hypopneas per hour) pre-operatively was 47.8 (range 20-92), post-operatively was 6.2 (range 0-14), and the mean improvement was 87%. Oxygen desaturation and REM sleep were also analyzed and will be reported. Conclusions: Distraction osteogenesis using a modified vertical ramus osteotomy with an internal device allows for preservation of the inferior alveolar nerve, minimizes the risk of injury to the facial nerve and dental elements, yields a favorable and nearly imperceptible aesthetic result, and provides for effective correction of ventilatory obstruction in the infant with a hypoplastic mandible. This study documents quantifiable pulmonary criteria for the clinical results of distraction osteogenesis, with an 87% improvement. Based upon our clinical experience, we recommend the use of DO in infants with MH and OSA with an AHI of >20.