Esophageal perforation in the neonate period is uncommon and often iatrogenic in origin, requiring a prompt diagnosis in order to prevent further complications. We present a case of iatrogenic esophageal perforation in a premature neonate following orogastric tube placement. Findings on plain film radiograph were consistent with thoracic esophageal perforation. Due to the patient’s hemodynamic stability, the patient was treated nonoperatively with favorable results. We also discuss the cause, clinical clues to the diagnosis and treatment in cases with esophageal perforation.