This Downes score calculator checks for respiratory distress in pediatric patients based on pulmonary function parameters such as respiratory rate. In the text below the form you can find more information on the way the score is calculated and on infant clinical signs of respiratory distress.


Respiratory rate




Air entry





How does the Downes score calculator work?

This health tool allows clinicians to evaluate infant respiratory function and to check for impending respiratory failure. The Downes score calculator consists of five respiratory parameters:

Respiratory rate – measured in breaths per minute. The normal rate for infants (newborn to 6 months) is 30 to 60. After 6 months, it decreases to 24 to 30 breaths per minute. This is one of the pediatric vital signs, along with heart rate, blood pressure or temperature.

Cyanosis – defined as a bluish discoloration of the skin and mucous membranes, usually caused by low oxygen saturation of the blood.

Air entry – evaluated by the intensity, loudness of the breathing sounds.

Grunt – defined as the expiratory noise produced by air pressing the partially closed glottis, during respiratory distress.

Retraction – defined as the sucking of the skin around and inward towards the chest bones during inspiration in respiratory distress.

Each of the five parameters is awarded a number of points ranging from 0 which means normal function, 1 point meaning moderate impairment and 2 points which means severe impairment in the function.

The Downes score is often represented in a table:

Item / Score 0 points 1 point 2 points
Respiratory rate (breaths/min) <60 60 - 80 >80
Cyanosis Nil In room air In ≥40%
Air entry Normal Mild decrease Marked decrease
Grunt None Audible with stethoscope Audible with naked ear
Retraction Nil Mild Moderate

Similar to this score, the Silverman score (also known as the Silverman-Anderson Index) evaluates respiratory distress based on upper chest, lower chest and xiphoid retractions, nasal flaring and expiratory grunt.

A comparison study between the two has found that the Downes score performs better in terms of accuracy and reliability. Although both are used in clinical studies, it seems that the Downes is preferred to the Silverman by health personnel, as it is easier to apply.

There are other infant scoring systems, that look only partially into respiratory function, such as the APGAR or the Pediatric Early Warning Score (PEWS).

Signs of respiratory distress

Difficulty breathing is important to diagnose with urgency, especially in neonates, preterm and term, especially because of the risk of impending respiratory failure. These are some of the most important clinical signs of respiratory distress:

Breathing rate – abnormal increase in the number of breaths per minute, usually above 60-80 in infants indicates lack of oxygen.

Heart rate – increases in heart rate can be caused by the insufficient oxygen levels.

Skin color changes – Bluish discoloration (cyanosis) around the mouth, inside of lips, paleness of the skin and fingernails.

Changes in alertness – that are consistent with respiratory fatigue.

Nose flaring – expansion of the nostrils due to difficulty of work of breath.

Grunting – sounds during expiration.

Chest retraction – the chest area appears to be sinking during each breath because of the labored work of breath.

Wheezing – represented by tight, whistling sound during each breath. It is a sign of impaired air passages.

Stridor – inspiratory sound coming from the upper airway.

Accessory muscle use – when the muscles of the neck appear to be moving during inhalation.

Sweating – along cool or clammy feel of the skin.


1) Downes JJ, Vidyasagar D, Boggs TR Jr, Morrow GM 3rd. (1970) Respiratory distress syndrome of newborn infants. I. New clinical scoring system (RDS score) with acid--base and blood-gas correlations. Clin Pediatr (Phila); 9(6):325-31.

2) Wood DW, Downes JJ, Lecks HI. (1972) A clinical scoring system for the diagnosis of respiratory failure. Preliminary report on childhood status asthmaticus. Am J Dis Child; 123(3):227-8.

3) Donahoe M. (2011) Acute respiratory distress syndrome: A clinical review. Pulm Circ; 1(2): 192–211.

4) Shashidhar A, Suman Rao PN, Joe J. (2016) Downes Score vs. Silverman Anderson Score for Assessment of Respiratory Distress in Preterm Newborns. Pediatric Oncall Journal; 13(3).

5) Greenough A, Roberton NRC. Acute respiratory disease in the newborn. In: JM Rennie editors. Textbook of Neonatology.  4th ed. China: Churchill Livingstone, 2005: 512-7.

6) Mathai SS, Raju U, Kanitkar M. (2007) Management of Respiratory Distress in the Newborn. Med J Armed Forces India; 63(3): 269–272.

24 Dec, 2016