Silverman-Andersen Respiratory Score Calculator
Silverman-Andersen Respiratory Score Calculator
Five signs of neonatal work of breathing, 0 to 10, and it runs the opposite way to the Apgar: here a HIGHER score is WORSE. The two are recorded on the same infant minutes apart, and inter-rater reliability for this one is poor.
Silverman-Andersen score
5 signs, 0 to 10, higher is worseUpper chest lagging on inspiration (1); just-visible intercostal retraction (1); no xiphoid retraction (0); minimal nasal flaring (1); no grunt (0)
Scoring, and the direction
Minimum 0 = no distress · maximum 10 = maximal distress · higher is worse, which is the opposite of the Apgar score
- the direction is the trap
- 0 is the well infant and 10 the worst. The Apgar score is scored on the same infant in the same minutes and runs the other way, 0 worst and 10 best. A transposed option set is invisible in the middle of the range and only shows at the ends, which is where this page’s own proof checks it
- why there are no bands here
- the 1956 paper used the retraction score as a trial endpoint and published no severity strata. The mild, moderate and severe categories printed by online calculators could not be traced to a primary source, so they are not reproduced: a band with no cohort behind it is an opinion with a colour attached
- inter-rater reliability is poor
- intraclass correlation 0.34 (95% CI 0.20 to 0.53) across 14 raters scoring 80 videos of 44 preterm infants in three Norwegian neonatal units; intra-rater reliability was good at 0.77 (0.68 to 0.84). One examiner following a trend is on much firmer ground than two examiners comparing totals
- it does measure something real
- in the same study, peak inspiratory diaphragm electrical activity correlated moderately with the mean inspiratory score (r = 0.468, p = 0.028). The signs are genuine markers of effort; the difficulty is grading them consistently
- a sixth sign it does not score
- respiratory rate is not an item. Tachypnoea is often the first change in a newborn with respiratory distress, and a Silverman score of 0 in a baby breathing 90 times a minute is a true score and a misleading summary
Worked example
Upper chest lagging on inspiration (1); just-visible intercostal retraction (1); no xiphoid retraction (0); minimal nasal flaring (1); no grunt (0)
1 + 1 + 0 + 1 + 0 = 3 points out of 10
Read the direction before reading the number. 3 here is a mildly increased work of breathing. An Apgar score of 3 in the same infant would be the opposite kind of news
Every item at 0 gives 0, the well infant. Every item at 2 gives 10, maximal distress. A score sheet filled in upside down gives 7 where 3 belongs and 10 where 0 belongs, and in the middle of the range it looks entirely plausible
Add grunting audible to the naked ear and the total is 5; that item is the most reliably scored of the five and the one whose mechanism is clearest, because grunting is an infant making their own end-expiratory pressure
Nothing here is a severity category. With an inter-rater intraclass correlation of 0.34, the difference between this examiner's 3 and the next examiner's 5 is within the noise of the instrument, and the trend recorded by one examiner is what carries information
The five signs
| Sign | 0 | 1 | 2 |
|---|---|---|---|
| Upper chest movement | Synchronised with the abdomen | Lag on inspiration | See-saw (paradoxical) |
| Lower chest (intercostal) retraction | None | Just visible | Marked |
| Xiphoid retraction | None | Just visible | Marked |
| Nasal flaring | None | Minimal | Marked |
| Expiratory grunt | None | Audible with a stethoscope | Audible to the naked ear |
Item-by-item agreement between examiners
| Item | Agreement (Kendall’s W) | Reading |
|---|---|---|
| Expiratory grunt | 0.67 | Substantial — an audible event |
| Xiphoid retraction | 0.44 | Moderate |
| Lower chest retraction | 0.43 | Moderate |
| Upper chest movement | 0.30 | Fair — the weakest item |
| Whole score, between raters | ICC 0.34 (0.20 to 0.53) | Poor |
| Whole score, same rater twice | ICC 0.77 (0.68 to 0.84) | Good |
The score that runs backwards, beside the score that does not
Five signs of a newborn struggling to breathe: does the upper chest move with the abdomen or against it, is there intercostal retraction, is there xiphoid retraction, is there nasal flaring, is there an expiratory grunt. Each 0, 1 or 2. Total 0 to 10, and 0 is the well infant. That last sentence is the whole reason this page exists in the form it does, because the other score written in the same notes in the same ten minutes of life runs the other way: an Apgar of 10 is a vigorous baby and a Silverman-Andersen of 10 is a baby in maximal distress. Two instruments, one infant, opposite polarity, and a total in the middle of the range looks equally plausible either way round.
The signs themselves are honest physiology. See-saw movement is a diaphragm pulling against a compliant chest wall that has nothing to brace against. Retractions are negative intrapleural pressure winning. Flaring reduces nasal resistance. Grunting is expiration against a partly closed glottis — an infant generating their own positive end-expiratory pressure, which is exactly why it vanishes when CPAP supplies that pressure from outside, and why a grunt that stops on support is a different event from a grunt that stops on its own. In the one study that measured it against something objective, peak inspiratory diaphragm electrical activity correlated moderately with the inspiratory score (r = 0.468).
Grading them consistently is the problem. Fourteen raters in three Norwegian neonatal units scoring 80 video recordings of 44 preterm infants produced an inter-rater intraclass correlation of 0.34, which is poor, while the same raters rescoring their own videos reached 0.77, which is good. The item-level pattern explains it: expiratory grunting, which you hear, reached substantial agreement; upper chest movement, which you judge by eye, reached only fair. A separate head-to-head study of interns and nurses in Bengaluru found this score’s intraclass correlation at 0.19 against the Downes score’s 0.51, with this score slower to complete and rated harder to use. None of that makes it useless; it makes the trend recorded by one examiner the signal, and a comparison between two examiners’ totals mostly noise. Note also what the score omits: respiratory rate is not an item, so a tachypnoeic newborn with no retraction scores 0.
A score is not a diagnosis, and a published figure describes the cohort it came from rather than the child in front of you. A single value is a snapshot of one examination: a child whose illness is evolving can score differently an hour later, so a reassuring score does not exclude deterioration, and the trend across serial assessments by the same examiner carries more than any one reading. The score was derived in premature infants with obstructive respiratory signs, as the outcome measure of Silverman and Andersen’s 1956 controlled trial of water mist, and it published no severity bands — which is why this page carries none. Published item wordings and severity bands differ between sources and between units, so the reader’s own unit’s chart and protocol take precedence over any banding printed here.
Frequently asked questions
Is a high Silverman-Andersen score good or bad?
Bad. 0 means no signs of increased work of breathing and 10 means all five signs at their most marked. It is the opposite direction to the Apgar score, which is recorded on the same infant in the same minutes, and mixing the two up is the commonest error with it.
What are the Silverman-Andersen severity bands?
The 1956 paper published none, and this page prints none. The mild/moderate/severe categories that appear on online calculators could not be traced to any primary source. With an inter-rater intraclass correlation of 0.34, a two-point difference between examiners is within the instrument’s own noise, so a category boundary drawn at two points is hard to defend.
How reliable is the Silverman-Andersen score?
Poor between examiners and good within one. A three-centre study of 14 raters scoring 80 videos of 44 preterm infants found an inter-rater intraclass correlation of 0.34 (95% CI 0.20 to 0.53) and an intra-rater value of 0.77 (0.68 to 0.84). Expiratory grunting was the most reliably scored item and upper chest movement the least.
Can I score it in a baby on CPAP or high-flow?
The reliability study scored infants on high-flow nasal cannula, CPAP and neurally adjusted ventilatory assist, so it is done — but two items are affected by the support itself. Nasal flaring is hard to see behind an interface, and grunting stops when external positive end-expiratory pressure replaces the infant’s own. Record the support alongside the score.
Silverman-Andersen or the Downes score?
They measure overlapping things and they are not interchangeable. In a head-to-head study of 40 interns and nurses in Bengaluru the two scores did not correlate significantly with each other (r = 0.189), the Downes score was more reliable (intraclass correlation 0.51 against 0.19) and faster (156 against 213 seconds), and the two were rated 3 and 5.5 out of 10 for difficulty. Record which one was used.
Related calculators
References
- Silverman WA, Andersen DH. A controlled clinical trial of effects of water mist on obstructive respiratory signs, death rate and necropsy findings among premature infants. Pediatrics. 1956;17:1–10. Citation as printed in the reference list of Chetan and Basu, Indian Pediatr, May 2018, page 438; the 1956 paper itself was not opened.
- Inter-rater reliability of the Silverman and Andersen index — a measure of respiratory distress in preterm infants. PLoS ONE. 2023;18(6):e0286655 (abstract and results read via DOAJ; trial registration NCT03199898).
- Downes score vs Silverman Anderson score for assessment of respiratory distress in preterm newborns. Pediatric Oncall Journal (accessed 10 October 2026) — 40 interns and nurses, St John’s Medical College, Bengaluru.
- Supplementary Table 1, Clin Exp Pediatr. 2025;68(9):680–689. doi:10.3345/cep.2025.00416 — an independent reproduction of the Silverman-Anderson item table used here for corroboration.
Not medical advice. For healthcare professionals and education. Reference intervals vary by laboratory and assay — always use your own laboratory's. Never base a dose or a treatment decision on this page alone. Full disclaimer at calcengines.com/disclaimer/