0 |
20 to 39 |
No accessory muscle use, no retractions |
Pink or mild cyanosis |
Playing/sleeping appropriately, baseline activity, smiling, and tracking parents |
No wound concern/rash |
Expected appearance |
1 |
40 to 49 |
Mild subcostal retractions |
Pale |
Sleepy, somnolent when not disturbed |
Wound infection concerns (erythema/swelling/discharge) or rash |
Mild concern |
2 |
50 to 59 |
Moderate subcostal retractions, flaring |
Gray |
Irritable, difficult to console |
|
Significant concern |
3 |
60 to 69 |
Suprasternal/intercostal retractions |
Gray and mottled |
Lethargic, floppy, reduced response to stimulation or pain |
|
|
4 |
<20 or ≥70 |
Severe subcostal retractions, head bobbing, paradoxical breathing |
|
|
|
|