Diaphragmatic paralysis was identified in four children after liver transplantation. All presented with persistent right upper lobe atelectasis, pleural effusion and recurrent respiratory infections and could not be weaned from mechanical ventilatory support. Fluoroscopy and real-time ultrasound confirmed paradoxical right diaphragmatic movements. Diaphragmatic plication was undertaken and enabled rapid and sustained weaning from respiratory support in all four cases. Vascular clamping of the suprahepatic vena cava seems to be the cause. Diaphragmatic plication allows optimal recruitment of the respiratory muscles with a favourable impact on lung mechanics and gas exchange.