Background: Numerous studies have shown the role of lung ultrasound in identifying etiology of respiratory distress in neonates. Aim of the Work: was to detect the efficacy of ultrasonography versus x-ray in identifying the etiology of respiratory distress in neonates. Patients and Methods: A cross sectional study that includes 50 neonates with respiratory distress. Each included subject was submitted to history taking, complete clinical examination and laboratory investigations including complete blood count and chest radiograph & US images. Results: In the present work, there was no significant difference among sex distribution and mode of delivery but male sex and cesarean sections are the predominant in each group. The reasons for respiratory distress from the clinical diagnosis were respiratory distress syndrome (n = 22), transient tachypnea of newborn (n = 23) and pneumonia (n = 5). The chest radiograph diagnosis of respiratory distress was RDS in 22 neonates, transient tachypnea of newborn in 24 neonates, pneumonia in 2 neonates and RDS or pneumonia in 2 neonates. Overall from the clinical scenario and radiological findings, the final diagnosis was RDS in 24 neonates, TTN in 24 neonates and pneumonia in 2 neonates. The ultrasound diagnosis of respiratory distress was RDS in 24 neonates, TTN in 24 neonates and pneumonia in 2 neonates. Conclusion: This study shows a clear superiority of lung ultrasound over the chest x-rays for the diagnosis of RDS, TTN and pneumonia. Chest Ultrasound cannot replace standard chest X-ray in detecting severity of neonatal RDS because of its tendency to overestimate RDS.