This Silverman score calculator evaluates the respiratory function of the pediatric patient and whether they are in respiratory distress. In the text below the form, there is more information on the score and its usage.


Upper chest retraction


Lower chest retraction


Xiphoid retraction


Nasal flaring


Expiratory grunt

How does the Silverman score calculator work?

This health tool is used to evaluate the pediatric patient’s work of breathing. It allows clinicians to quickly recognize respiratory distress or its impending presence.

Also known as the Silverman-Anderson Index, the score supports the evaluation of 5 breathing parameters:

Upper chest retraction – represents the sucking of the skin between or around the chest bones when inhaling. It represents a sign of breathing difficulty.

Lower chest retraction – same as the above, but in a lower position. Subcostal retractions occur just below the rib cage.

Xiphoid retraction – sign of respiratory distress, common in preterm infants and characterized by the visual sinking of the xiphoid process.

Nasal flaring – the widening of the nostrils during breathing with difficulty.

Expiratory grunt – the noise produced during expiration in respiratory distress. Caused by the breath going against the partially closed glottis.

These are awarded points, from 0 to 2, on a scale that is essentially from normal to severe impairment. The score is often represented in a table:

Item / Score 0 points 1 point 2 points
Upper chest retraction Synchronized Lag on inspiration See-saw respiration
Lower chest retraction None Just visible Marked
Xiphoid retraction None Just visible Marked
Nasal flaring None Minimal Marked
Expiratory grunt None Audible with stethoscope Audible with naked ear

The Silverman score calculator interprets the results as follows:

Scores: 0 – 3: none to mild respiratory distress.

Scores 4 – 6: moderate respiratory distress.

Scores >6: impending respiratory failure.

Infants with normal breathing tend to have scores closer to 0 whereas severely respiratory depressed infants get scores closer to 10, the maximum obtainable.

The score is often used in clinical studies, just like its counterpart, the Downes score which has the same function to discover respiratory distress but uses other parameters. As a comparison between the two scores, the Downes was found to have better accuracy and reliability.

As a category, the Silverman score belongs to the infant scoring systems, along with APGAR.

Clinical signs of pulmonary disease in infants

There are several signs of pulmonary disease in pediatric patients such as a respiratory rate above 60 breaths per minute (tachypnea), wheezing that can suggest pulmonary edema, rales that can indicate fluid, retractions indicating increased work of breathing, nasal flaring and grunting.

Conditions that cause respiratory distress in preterm babies include respiratory distress syndrome, hypoglycemia, hypothermia or congenital pneumonia.

In the case of term babies, respiratory distress may be caused by transient tachypnea of newborn, meconium aspiration, pneumonia, asphyxia, tracheo-esophageal fistula or diaphragmatic hernia, amongst other cardiac, metabolic or surgical causes.


1) Silverman WA, Andersen DA. (1956) A controlled clinical trial of effects of water mist on obstructive respiratory signs, death rate and necropsy findings among premature infants. Pediatrics; 17(1):1–10.

2) Dambeanu JM, Parmigiani S, Marinescu B, Bevilacqua G. (1997) Use of surfactant for prevention of respiratory distress syndrome in newborn infants in spontaneous breathing. A randomized multicentre clinical pilot-study. Acta Biomed Ateneo Parmense; 68 Suppl 1:39-45.

3) 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).

4) Silverman W, Anderson D. (1956) Pediatrics 17:1.

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

24 Dec, 2016