Newborn · Respiratory
Silverman-Andersen Score & Newborn Respiratory Distress
5-item respiratory distress assessment (0-10): chest retractions, nasal flaring, grunting. Higher = more distressed. Used for RDS, TTN, meconium aspiration. Silverman 1956. NICE NG25.
Last reviewed 2 June 2026
Silverman-Andersen retraction score
Neonatal respiratory distress severity
Score all 5 items to see total.
Educational tool only — not medical advice. Silverman-Andersen 1956 — the classic bedside neonatal respiratory distress score. Used worldwide especially in low-resource settings where ventilator decisions are made at bedside. Downes score (1976) is an alternative with similar properties. Severe respiratory distress in a neonate is always a NICU-level emergency.
What does this mean?
The Silverman-Andersen score (1956) is one of the oldest still- used bedside tools in neonatology — 5 visual signs of work of breathing scored 0–2 each, total 0–10. Score 0–3 = no/mild distress; 4–6 = moderate, likely needs nasal CPAP / high-flow oxygen and a paediatric review; 7–10 = severe, likely surfactant + mechanical ventilation. Cause is most often respiratory distress syndrome (surfactant deficiency in preterms), transient tachypnoea of the newborn (slow lung-fluid clearance after C-section), meconium aspiration, pneumonia, or persistent pulmonary hypertension. Treatment ladder: warm + position + gentle stimulation, oxygen as needed, CPAP (the workhorse for mild–moderate RDS), surfactant via LISA / INSURE technique, mechanical ventilation. The Downes score is an alternative with similar properties.
What is the Silverman-Andersen score?
Newborn respiratory distress assessment. 5 items, each 0-2:
- Upper chest movement.
- Lower chest (subcostal) retractions.
- Xiphoid retractions.
- Nasal flaring.
- Expiratory grunt.
Score 0-10. Lower = better.
- 0-3: mild.
- 4-6: moderate.
- 7-10: severe.
Signs of respiratory distress
- Fast breathing (>60/min).
- Grunting on each breath out.
- Nasal flaring.
- Chest / ribs / neck retractions.
- Head bobbing.
- Cyanosis (blue tinge to lips, tongue).
- Low oxygen saturation.
Common causes
- RDS: surfactant deficiency in preterm.
- TTN: delayed lung fluid absorption; common post-C-section; resolves 24-72h.
- Meconium aspiration.
- Pneumonia / sepsis.
- Pneumothorax.
- Congenital anomalies.
RDS (Respiratory Distress Syndrome)
Lung disease of prematurity. Surfactant deficiency. Risk: 60% of <30 wk; <5% at 38+ wk.
Treatment: surfactant via tracheal tube; CPAP / ventilation; antenatal steroids before delivery reduce severity.
TTN (Transient Tachypnoea)
Delayed fluid absorption. Common after C-section. Resolves 24-72h without specific treatment. Supportive oxygen if needed.
CPAP support
- Nasal prongs or mask deliver constant air/oxygen pressure.
- Keeps lungs inflated; non-invasive.
- Less lung damage than ventilation.
- Preferred when possible.
Surfactant treatment
Artificial surfactant via tracheal tube. INSURE (brief intubation for surfactant then extubate to CPAP) or LISA/MIST (catheter on CPAP, increasingly used UK). Earlier surfactant = better outcomes.
Ventilator
Mechanical breathing support via tube. For severe RDS, apnoea, severe hypoxia. Risks: BPD (bronchopulmonary dysplasia), pneumothorax. Aim for minimal duration.
Holding baby on CPAP
Often yes — skin-to-skin (kangaroo care) improves outcomes. Nurse will help. Ventilator: usually cannot hold; express milk + bedside presence.
Breastfeeding
- Mild distress: usually breastfeed normally.
- CPAP: NG tube initially; transition when stable.
- Ventilator: NG/IV nutrition; express every 2-3h.
- Lactation consultant support.
Long-term outlook
Mild RDS treated promptly: usually no long-term issues. Severe RDS / BPD: possible asthma-like symptoms in childhood; may need inhalers; usually improve through childhood. Annual flu vaccine; RSV protection.
Different scenarios
Scenario 1: Term baby, mild tachypnoea after C-section, score 3
Likely TTN. Observation; oxygen if needed; resolves 24-72h.
Scenario 2: 30-wk preterm, severe distress, score 8
NICU. CPAP or surfactant + ventilator. Antenatal steroids hopefully given.
Scenario 3: Meconium-stained liquor, vigorous baby, mild distress
Observation. Score-monitored. Usually clears within hours-day.
Scenario 4: Term baby, distress + sepsis suspected
Empirical antibiotics. CXR. Investigation for cause.
Scenario 5: 26-wk preterm, severe RDS, ventilated
NICU long-term. Surfactant. Transition CPAP when possible. BPD risk; follow-up.
Care guidance — respiratory distress
- Any newborn distress: urgent assessment.
- Antenatal steroids prevent severe preterm RDS.
- CPAP first-line for mild-moderate.
- Surfactant for RDS.
- Skin-to-skin when stable.
- Express breast milk early.
- NICU stay variable.
- Follow-up developmental + respiratory clinics.
- BLISS UK support.
Sources
- Silverman WA, Andersen DH. A controlled clinical trial of effects of water mist on obstructive respiratory signs. Pediatrics 1956.
- NICE NG25. Preterm labour and birth.
- European Consensus Guidelines on Management of RDS (2022).
- Resuscitation Council UK. Newborn Life Support.
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Frequently asked questions
What is the Silverman-Andersen score?
Clinical SCORE for NEONATAL RESPIRATORY DISTRESS. Five observations of breathing effort, each 0-2 (0 = normal, 2 = severe). TOTAL 0-10. Lower = better. Developed by William Silverman + Dorothy Andersen 1956 — still useful today. 5 ITEMS: (1) UPPER CHEST movement; (2) LOWER CHEST (subcostal retractions); (3) XIPHOID retractions; (4) NASAL FLARING; (5) EXPIRATORY GRUNT. SCORE: 0-3 mild; 4-6 moderate; 7-10 severe respiratory distress.
When is the score used?
POSTNATAL ASSESSMENT — first hours of life. Common in: preterm babies; suspected respiratory distress syndrome (RDS); transient tachypnoea of newborn (TTN); meconium aspiration; sepsis; congenital lung issues. REPEATED ASSESSMENTS guide management. ESCALATION based on score + clinical picture + oxygen needs + blood gases. NICU usually involved if score moderate-severe.
What are the signs of respiratory distress?
VISIBLE WORK OF BREATHING: (1) FAST BREATHING (>60/min in newborn); (2) GRUNTING — short audible noise on each breath out (baby's attempt to keep airways open); (3) NASAL FLARING — nostrils widening with each breath; (4) RETRACTIONS — chest/ribs/neck pulling in with breath; (5) HEAD BOBBING (uses neck muscles); (6) CYANOSIS — blue tinge to lips, tongue, mouth area (central); (7) OXYGEN SATURATION low. ANY signs in newborn: urgent assessment.
What causes respiratory distress?
(1) RESPIRATORY DISTRESS SYNDROME (RDS) — surfactant deficiency in preterm babies; (2) TRANSIENT TACHYPNOEA OF NEWBORN (TTN) — delayed lung fluid absorption, common after C-section; usually resolves in 24-72h; (3) MECONIUM ASPIRATION SYNDROME (MAS); (4) PNEUMONIA / SEPSIS; (5) AIR LEAKS (pneumothorax); (6) CONGENITAL anomalies (CDH, lung lesions, cardiac); (7) HYPOTHERMIA; (8) HYPOGLYCAEMIA can mimic. CXR, blood gas, septic screen guide diagnosis.
What is RDS?
RESPIRATORY DISTRESS SYNDROME — lung disease of prematurity. SURFACTANT (substance that keeps air sacs open) is produced from 24-26 weeks, fully by 35 weeks. PRETERM BABIES <34 wk have surfactant deficiency → lungs collapse on each breath. SIGNS: distress at or soon after birth; progressive worsening over 12-24h. RISK: 60% of <30wk; <5% at 38+ wk. TREATMENT: surfactant via tracheal tube; CPAP/ventilation; antenatal steroids before delivery prevent or reduce. PRETERM survival now >90% at 28+ wk in modern NICU.
What is TTN?
TRANSIENT TACHYPNOEA of newborn. AT BIRTH: lungs full of fluid; vaginal birth squeezes most out; remainder absorbed. AFTER C-SECTION (especially without labour) or rapid vaginal birth: fluid clearance delayed. PRESENTATION: tachypnoea (fast breathing), mild retractions, sometimes oxygen requirement; CHEST X-RAY shows fluid lines; resolves in 24-72 HOURS without specific treatment. SUPPORTIVE care: oxygen if needed, observation. EXCLUDE infection (sepsis screen often done).
What's CPAP?
CONTINUOUS POSITIVE AIRWAY PRESSURE — non-invasive breathing support. NASAL prongs or mask deliver constant air/oxygen pressure to keep lungs inflated. AVOIDS need for full ventilator + ET tube in many babies. INDICATIONS: respiratory distress (RDS, TTN, apnoea of prematurity). LESS LUNG DAMAGE than ventilation; preferred when possible. SOME UK NICUs use 'CPAP from delivery room' approach for preterm. SUCCESS RATE high in 28+ week babies. ESCALATE to ventilation if not maintaining oxygen / CO2.
What's surfactant treatment?
ARTIFICIAL SURFACTANT (animal-derived or synthetic). REPLACES missing surfactant in preterm RDS. ADMINISTERED via tracheal tube; usually in NICU. RAPIDLY improves lung function. MAY allow EXTUBATION to CPAP. INSURE technique (Intubation + Surfactant + Extubation): brief intubation just for surfactant, then immediate extubation to CPAP. LISA (Less Invasive Surfactant Administration) / MIST (Minimally Invasive Surfactant Therapy): surfactant via thin catheter while on CPAP; UK NHS increasingly. EARLIER surfactant better outcomes.
What's the ventilator?
MECHANICAL BREATHING SUPPORT via endotracheal tube. INDICATIONS: severe RDS not responding to CPAP; apnoea; severe hypoxia; muscle weakness. MODES: SIMV (intermittent mandatory ventilation); HFOV (high-frequency oscillatory); HFJV (high-frequency jet). RISKS: lung damage (BPD — bronchopulmonary dysplasia), pneumothorax. AIM: minimal duration; transition to CPAP / nasal cannula. CHRONIC LUNG DISEASE possible in extreme prematurity needing prolonged ventilation.
Will my baby have long-term lung issues?
DEPENDS on severity + duration. MILD RDS treated promptly: usually no long-term issues. SEVERE RDS / chronic lung disease (BPD): possible asthma-like symptoms in childhood; may need long-term inhalers; usually improve through childhood; some long-term reduced lung function in extreme prematurity. ANNUAL flu vaccine; RSV protection (palivizumab / nirsevimab for high-risk preterm). FOLLOW-UP through paediatric / respiratory clinics. MOST do well.
What's the difference between mild and severe distress?
SILVERMAN-ANDERSEN 0-3 = MILD: minimal effort signs; usually self-resolves or needs minimal oxygen; observation. 4-6 = MODERATE: clear distress signs; may need CPAP, oxygen, NICU; investigation underway. 7-10 = SEVERE: extreme work of breathing; usually needs intubation + ventilation; intensive treatment. CLINICAL CONTEXT matters — preterm + score 4 different from term + score 4. REPEAT ASSESSMENT key for tracking trajectory.
Can I hold my baby on CPAP?
OFTEN YES. CPAP allows baby to remain with parent for skin-to-skin (kangaroo care) — proven benefits for stable preterm + term babies. NURSE will help position baby + maintain CPAP integrity. CABLES + tubing manageable. PARENTAL contact reduces stress hormones, improves outcomes, supports breastfeeding when ready. ASK NURSE / NICU team about your options. SOME babies on ventilator cannot be held — express milk + bedside presence.
Can I breastfeed?
DEPENDS on severity. SHORT respiratory distress: usually breastfeed normally. CPAP babies: NG (nasogastric) tube feeding initially; transition to breast/bottle when stable. VENTILATED: NG/IV nutrition; express milk regularly to maintain supply for when baby ready. LACTATION CONSULTANT support essential. CONTINUE pumping every 2-3 hours including night. SKIN-TO-SKIN improves milk production + bonding.
What antenatal steroids do?
BETAMETHASONE / DEXAMETHASONE injections to mum if preterm delivery anticipated 24-34 weeks. CROSS placenta → speed up baby's lung maturation. SIGNIFICANTLY REDUCE RDS severity. NICE NG25 protocol. BIGGEST evidence-based intervention to prevent severe respiratory issues in preterm. EVEN ONE DOSE has benefit; full course (2 doses 24h apart) optimal. ALWAYS asked about / given if preterm birth likely within 7 days. /calculators/antenatal-steroids for detail.
How does this relate to other calculators on BumpBites?
Companion: /calculators/apgar-score; /calculators/nrp-algorithm; /calculators/new-ballard; /calculators/antenatal-steroids; /calculators/sarnat-hie; /calculators/eos-sepsis (sepsis can cause respiratory distress); /calculators/baby-cough; /calculators/pram-asthma.