What it is
The Silverman-Andersen score is a bedside grading of the work of breathing in a newborn. Unlike oximetry, it captures the visible mechanical effort an infant is expending — useful precisely when saturations still look acceptable but the baby is fatiguing. It was designed for preterm infants with hyaline membrane disease and remains a quick, equipment-free way to track respiratory distress and the response to support.
The five signs
Each of five signs scores 0, 1, or 2, summing to 0–10. Higher is worse (the inverse of an Apgar, where higher is better).
- Upper chest movement: synchronised (0) · lag on inspiration (1) · see-saw (2)
- Lower chest retraction: none (0) · just visible (1) · marked (2)
- Xiphoid retraction: none (0) · just visible (1) · marked (2)
- Nasal flaring: none (0) · minimal (1) · marked (2)
- Expiratory grunt: none (0) · audible with stethoscope (1) · audible unaided (2)
Doctaverse bands the total as:
- 0 — No respiratory distress
- 1–3 — Mild
- 4–6 — Moderate
- 7–10 — Severe / impending failure
A score of 0 means even, unlaboured breathing — note that the original chart labelled this as the absence of distress, so do not read a normal baby as “mild.”
When to use it
- Initial assessment of any neonate with tachypnoea, grunting, or retractions.
- Serial scoring to trend trajectory and titrate support (CPAP, FiO₂), since a single number matters less than its direction over time.
- Communicating severity concisely on rounds or in transfer notes.
Worked example
A 32-week infant has see-saw breathing (2), marked lower chest retraction (2), just-visible xiphoid retraction (1), minimal nasal flaring (1), and grunting audible with a stethoscope (1).
Total = 2 + 2 + 1 + 1 + 1 = 7/10 → Severe / impending failure. This infant warrants prompt escalation of respiratory support and blood-gas assessment rather than watchful waiting.
Pitfalls
- It grades effort, not gas exchange. A tiring infant can score lower as they decompensate toward apnoea — falling effort with rising CO₂ is ominous, not reassuring. Interpret alongside blood gases and tone.
- See-saw paradox. The worst upper-chest pattern (chest in, abdomen out) reflects diaphragmatic breathing against a non-compliant chest — easy to miss if you watch only the abdomen.
- Subjectivity. Grunting “audible unaided” versus “with stethoscope” and “marked” versus “just visible” retractions vary between observers; standardise who scores and how.
- It is validated for distress severity, not as a standalone trigger for any specific intervention — pair it with the full clinical picture.
Run it: Silverman-Andersen Score
Decision support for qualified clinicians only — verify against current primary guidelines and your clinical judgement.