Esophageal perforation, a well-known entity in adults, is relatively uncommon in infants and children. Aggressive management in neonatal intensive care units have led to increased survival of premature infants and very sick babies. But it have led to unusual complication like iatrogenic perforation. Perforation of the esophagus or pharynx may occur during replacement of endotracheal or nasogastric tubes in the newborn infant. We recently experienced a case of esophageal perforation presenting with pneumomediastinum in premature infant, which was induced by gastric tube insertion and managed medically. We think that prevention is more important. So, careful visualization of vocal cord during intubation, gentle laryngoscopy, and the use of a soft rubber catheter for oral suction are needed.