Grading Chest Wall Retractions
Chest wall retractions are graded as mild, moderate, or severe based on the presence and combination of specific respiratory distress signs, with severity determined by the anatomical location and extent of indrawing along with associated danger signs.
Grading System
The grading is based on a clinical assessment framework that evaluates multiple components of respiratory distress 1:
Mild Retractions
- Intercostal retractions only (indrawing between the ribs)
- No other signs of severe respiratory distress
- Child able to drink and feed normally
- No general danger signs present
Moderate Retractions
- Chest indrawing (lower chest wall indrawing)
- May include persistent nasal flaring
- Tachypnea present for age
- Child still able to drink but with some difficulty
Severe Retractions
Any of the following indicate severe respiratory distress 1:
- Pronounced lower chest wall indrawing
- Head nodding
- Persistent nasal flaring
- Grunting
- Stridor while calm
- Tracheal tugging
- Intercostal retractions combined with other danger signs
- Very fast breathing for age
Clinical Context
The severity assessment should be integrated with WHO general danger signs 1:
- Inability to drink
- Vomiting everything
- Convulsions
- Lethargy or unconsciousness
- Severe malnutrition
- Stridor in a calm child
A child with chest indrawing plus any general danger sign should be classified as having severe disease, regardless of the degree of retractions alone 1.
Important Caveats
- The grading system is most validated in pediatric pneumonia assessment, where chest indrawing is a key clinical sign 1
- In croup specifically, chest wall indrawing is used as one component of severity scoring alongside barky cough and stridor 2
- The anatomical location matters: lower chest wall indrawing is more concerning than isolated intercostal retractions
- Hypoxemia (SpO₂ <93%) should elevate any case to severe, regardless of the degree of visible retractions 1