Retracted breathing in babies shows up as visible inward pulling of the skin and soft tissue around the ribcage, breastbone, or neck each time the baby takes a breath in. Instead of the chest expanding smoothly, you see small dips or sinking areas where the baby’s muscles are working harder than normal to draw air into the lungs. The pulling can appear in several different spots on the torso and neck, and its location and depth give clinicians clues about how hard a baby is struggling to breathe. Because retractions signal that something is making breathing more difficult than it should be, recognizing what they look like is one of the most practical things a parent or caregiver can learn.
Where on the Body Retractions Appear
Retractions are not a single look. They show up in distinct zones, and each zone has its own name in medical shorthand. Knowing the zones helps because some indicate milder effort while others suggest more serious distress.
- Subcostal: Inward pulling just below the bottom edge of the ribcage, where the ribs meet the upper abdomen. This is one of the earliest and most common spots to see tugging in a baby who is working harder to breathe.
- Intercostal: Small dips that appear between individual ribs during each inhalation. You can sometimes count the rib outlines more clearly than you normally would because the skin between them sinks inward.
- Substernal (xiphoid): A visible dip right at the bottom of the breastbone, roughly in the center of the upper belly. This area is soft in babies, so it sinks noticeably when breathing effort increases.
- Suprasternal: A hollow or dip in the soft notch at the base of the throat, just above the breastbone. When you see pulling here, it often points to an obstruction higher up in the airway, such as croup or another cause of upper airway narrowing.
- Supraclavicular: Pulling in the hollows above the collarbones, on either side of the lower neck. Like suprasternal retractions, these tend to signal significant effort.
Mild distress might show only subcostal or lower intercostal tugging. As a baby works harder, you begin to see retractions creep upward toward the neck. By the time suprasternal and supraclavicular pulling are clearly visible, the baby is typically in more serious trouble. The pattern does not always follow a neat progression, but in general, more zones involved and deeper pulling means more work of breathing. When clinicians describe “chest indrawing,” they are referring to this same visible sinking of tissue around the chest wall, and its presence increases the likelihood of conditions like pneumonia.1JAMA. Does This Infant Have Pneumonia?
Why Babies Are Especially Vulnerable
Adults and older children can have retractions too, but they are far more visible and common in infants. The reason is structural. A newborn’s chest wall is extremely soft and flexible compared to an adult’s. The ribs are largely cartilage rather than solid bone, and the muscles between and around the ribs are less developed. This high compliance allows the chest to expand easily during normal breathing, but it also means the chest wall collapses inward more readily when the baby has to generate extra suction to pull air past any obstruction or into stiff lungs.
Research on neonatal chest wall mechanics shows that in babies under one year, the chest wall is roughly three times as compliant as the lung itself. By the second year of life, the chest wall stiffens enough that it and the lung become close to equally compliant, which is similar to the adult ratio.2PubMed Central. Developmental changes in chest wall compliance in infancy and early childhood That dramatic mismatch in very young babies is why retractions are so prominent in the first year of life. Even modest increases in airway resistance or lung stiffness create visible chest wall distortion in an infant that would barely register on the surface of an older child’s body.
On top of the soft chest wall, newborn diaphragm muscles have fewer fatigue-resistant muscle fibers than adult diaphragms. So not only does the baby’s chest pull inward more easily, but the baby’s primary breathing muscle also tires out faster. That combination of a floppy chest wall and a fatigue-prone diaphragm raises the risk of breathing failure if the underlying problem is not addressed.3PubMed Central. Role of the Chest Wall in Newborn Respiratory Function at Birth
Other Signs That Often Appear Alongside Retractions
Retractions rarely appear in isolation. When a baby is struggling to breathe, a cluster of related signs usually shows up at the same time. Respiratory distress in newborns commonly presents as a package of fast breathing, nasal flaring, retractions, and grunting.4PubMed Central. Respiratory distress in the newborn Understanding these companion signs helps you judge the severity of what you are seeing.
Nasal flaring is the widening of the nostrils with each breath in. Babies breathe primarily through their noses, and flaring is an instinctive attempt to open the airway wider and reduce resistance. It is one of the earlier visible signs, sometimes appearing before retractions become obvious. Fast breathing, or tachypnea, is another hallmark. In a newborn, normal resting respiratory rate is roughly 30 to 60 breaths per minute; rates persistently above that range are concerning. In older infants and toddlers, normal rates are lower, so the threshold shifts with age.
Grunting is a short, low-pitched sound the baby makes at the end of each breath out. It can sound like a small moan or a rhythmic “uh” with each exhale. Far from being random noise, grunting is actually a physiological strategy: the baby is partially closing the vocal cords during exhalation to create back-pressure, which keeps the small air sacs in the lungs from collapsing. Studies of infants with lung disease have shown that oxygen levels in the blood drop when grunting is prevented, confirming that it serves a real protective function.5Archives of Pediatrics & Adolescent Medicine. Significance of Grunting Respirations in Infants Admitted to Well-Baby Nursery Grunting combined with retractions is a red flag that the baby needs medical evaluation promptly.
Other visual clues include color changes, particularly a bluish tint around the lips or fingertips, and a head-bobbing motion in very young infants where the head nods forward with each breath because the neck muscles are being recruited to assist respiration. Altered behavior matters too: a baby who is unusually lethargic, difficult to wake, or not feeding well alongside any visible breathing changes warrants urgent attention.
Common Causes of Retractions in Infants
Retractions are a sign, not a diagnosis. Many different conditions can produce them, and the specific cause matters because treatment varies widely.
Bronchiolitis, most often caused by respiratory syncytial virus (RSV), is one of the most frequent triggers in babies under two. The virus attacks the small airways, causing swelling, mucus buildup, and plugging that traps air. The resulting mix of wheezing, patchy lung collapse, and overinflation is what forces the baby to work so hard to move air in and out.6Pediatrics in Review. Respiratory Syncytial Virus Infection and Bronchiolitis Retractions in bronchiolitis are typically widespread across the lower chest, and you often hear audible wheezing at the same time.
Pneumonia is another major cause. In infants under six months, chest indrawing has been found to be a highly specific indicator of pneumonia, meaning that when it shows up, the chances are strong that pneumonia is present, even though not every baby with pneumonia will display it.7Brazilian Journal of Infectious Diseases. Signs and symptoms indicative of community-acquired pneumonia in infants under six months Clinicians often treat visible chest indrawing in a young infant as grounds for hospitalization because it signals a more severe case.
Croup and other forms of upper airway obstruction produce a different pattern. Because the blockage is higher up, you tend to see prominent suprasternal retractions along with a characteristic barking cough and stridor, which is a harsh, high-pitched sound during inhalation. Stridor combined with suprasternal pulling are considered hallmark signs of upper airway obstruction.8PubMed. Acute upper airway obstruction
In newborns specifically, conditions like respiratory distress syndrome (related to lung immaturity, especially in premature babies), transient tachypnea of the newborn, and meconium aspiration can all produce retractions in the first hours or days of life. In these cases, clinicians are already watching closely in the nursery or neonatal unit.
Retractions in Premature Babies
Premature infants face a double disadvantage. Their lungs are less mature, meaning they produce less surfactant, the substance that keeps air sacs from sticking shut. And their chest walls are even more compliant than those of full-term newborns because the ribs are softer and the muscles less developed. As a result, retractions tend to appear earlier and look more dramatic in a preemie than in a term baby with the same underlying lung problem.
In neonatal intensive care units, staff assess retractions as part of structured scoring systems. One widely used tool, the Silverman-Andersen score, grades five components of breathing effort including upper chest movement, lower chest retractions, xiphoid retraction, nasal flaring, and expiratory grunting. Each component gets a score from zero to two, with higher totals meaning worse distress. A study of newborns found that those scoring five or above on this scale had their respiratory support escalated within 24 hours far more often than those below five.9PubMed Central. Performance of the Silverman Andersen Respiratory Severity Score in predicting PCO2 and respiratory support in newborns: a prospective cohort study
The scoring system is useful, but it is not perfectly reliable even among trained clinicians. Research comparing how different doctors and nurses rate the same videos of breathing babies found only poor to moderate agreement on several components, with slightly better agreement for grunting than for chest movements.10PLOS ONE. Inter-rater reliability of the Silverman and Andersen index-a measure of respiratory distress in preterm infants That inconsistency underscores why clinicians do not rely on any single score in isolation; they combine the visual assessment with oxygen saturation monitors, blood gas readings, and the baby’s overall clinical picture.
Why Recognizing Retractions Can Be Tricky for Parents
Most parents have never been taught to look for retractions, and the signs can be subtle in the early stages. A study that showed parents video clips of children with various respiratory symptoms found that correct identification of abnormal breathing patterns was far from universal. Parents correctly labeled wheezing about 59% of the time and were even less accurate with other abnormal sounds like stridor, managing about 47% accuracy. They also had a significant rate of false positives, calling normal breathing abnormal about a quarter to a third of the time for certain sounds.11BMJ Publishing Group Ltd. Parents’ interpretations of children’s respiratory symptoms on video
Retractions specifically can be hard to spot if the baby is clothed, swaddled, or moving around. To see them, you need the baby’s chest and upper abdomen exposed, with good lighting, ideally while the baby is relatively still. Looking from the side can help you catch the inward pull below the ribs or at the breastbone that might not be as obvious from straight on. Very mild retractions might show only as a slight dimpling between the lower ribs with each breath, which can be easy to dismiss as normal.
A practical tip: if you suspect your baby is breathing harder than usual, count the breaths over a full 60 seconds while the baby is calm and at rest. Fast breathing paired with visible skin pulling anywhere around the chest or neck is a combination that warrants a call to your pediatrician or a trip to urgent care. Do not wait for the baby to turn blue; retractions often appear well before oxygen levels drop to dangerous levels, and that lead time is an advantage if you act on it.
How Training Improves Recognition
Even healthcare professionals benefit from structured training on identifying retractions and other signs of respiratory distress. A study in a low-resource setting showed that after nurses received training on using the Silverman-Andersen scoring system, their ability to identify mild respiratory distress jumped from 63% to 93%, and identification of moderate distress rose from 40% to 73%. Overall agreement among the nurses improved substantially, mainly because training reduced the tendency to overestimate milder cases.12PubMed. Training on the Silverman and Andersen score improved how special care unit nurses assessed neonatal respiratory distress in a low-resource setting
This finding has implications beyond clinical settings. If trained nurses significantly improve their accuracy with a focused educational intervention, parents could potentially benefit from similar visual training materials. Some pediatric organizations and hospitals have started creating short video guides showing what retractions look like at different severity levels, though standardized parent education tools remain uncommon. If your pediatrician’s office offers any visual materials or video demonstrations, they are worth watching, especially before your baby’s first cold season.
Remote Assessment and When Video Calls Fall Short
Telemedicine visits have become more common, and parents often wonder whether a doctor can assess a baby’s breathing over video. A pilot study looking at the feasibility of remote respiratory assessments in children found that parents and local clinicians showed excellent agreement when identifying retractions. However, agreement between the remote clinician and either the parent or the local clinician was substantially lower for retractions specifically, even though overall impressions of respiratory distress had acceptable agreement across all pairings.13PubMed Central. Feasibility and reliability of telemedicine examinations for respiratory distress in children: A pilot study
Camera angle, lighting, video quality, and the baby’s movement all make it harder for a clinician watching through a screen to catch the subtle inward pulling of soft tissue. If you need to show your baby’s breathing to a doctor over a video call, undress the baby’s upper body, use the brightest light you have, position the camera at chest level rather than looking down from above, and try to keep the baby relatively still. Even with these steps, a remote clinician may recommend an in-person visit if they cannot confidently assess the degree of retractions. This is not overcaution; it reflects a real limitation of video assessment for this particular sign.
What Happens When a Baby With Retractions Gets to the Hospital
If your baby arrives at an emergency department or urgent care with visible retractions, clinicians will typically move quickly. The first step is usually measuring oxygen saturation with a small clip on the baby’s finger or toe. They will count the respiratory rate, listen to the lungs with a stethoscope, and assess which zones of retractions are present and how deep they are. Based on the overall picture, they may order a chest X-ray or blood work, though not always; in straightforward cases of bronchiolitis, for instance, the diagnosis is often clinical.
Treatment depends on the cause and severity. For many babies with mild to moderate distress, supplemental oxygen delivered through a nasal cannula is enough. High-flow nasal cannula therapy has become a common step up from simple oxygen, particularly for bronchiolitis. It delivers warmed, humidified air at higher flow rates, which creates a small amount of positive pressure in the airways that helps keep them open. Studies of children treated with high-flow nasal cannula showed significant improvements in clinical distress scores and oxygen saturation, and chest X-rays taken afterward showed improved or unchanged lung aeration in the large majority of patients.14PubMed. Children with respiratory distress treated with high-flow nasal cannula Research in infants with bronchiolitis specifically has suggested that high-flow nasal cannula may reduce the need for intubation by decreasing the respiratory rate and the work of breathing in a way that babies tolerate well.15PubMed. High flow nasal cannulae therapy in infants with bronchiolitis
For babies with severe distress who do not improve on noninvasive support, continuous positive airway pressure (CPAP) or mechanical ventilation may be needed. Premature newborns with respiratory distress syndrome may also receive surfactant, a medication delivered directly into the lungs to replace what their immature lungs are not producing enough of. The goal throughout is to reduce the work of breathing so the baby’s muscles are not fighting a losing battle against a floppy chest wall and a lung that is not cooperating.
Retractions That Are Not an Emergency
Not every instance of visible chest pulling means a trip to the emergency room. Babies with a mild cold can show faint subcostal retractions that resolve once you suction mucus from the nose or run a cool-mist humidifier. Some otherwise healthy newborns display brief, mild retractions during the first day of life as they clear residual fluid from their lungs, a self-limiting condition known as transient tachypnea of the newborn. In these situations, the retractions are shallow, the baby feeds normally, maintains good color, and does not appear distressed.
The red flags that tip the balance toward urgent evaluation include retractions that are deepening or spreading to more zones over time, retractions accompanied by grunting or color changes, a baby who refuses to feed or is unusually sleepy, and retractions that persist beyond a few hours without improvement. If you are on the fence, calling your pediatrician and describing what you see is always reasonable. Describing the location of the pulling (under the ribs, between the ribs, at the throat) and whether you hear any unusual sounds gives the clinician much more to work with than a vague report of “trouble breathing.”