Mild or absent respiratory distress: - Increased RR, but less than the age-specific RR that defines moderate to severe respiratory distress
- Mild or absent retractions
- No grunting
- No nasal flaring
- No apnea
- Mild shortness of breath
| Moderate to severe respiratory distress: - RR >70 breaths/minute for infants; RR >50 breaths/minute for older children
- Moderate/severe suprasternal, intercostal, or subcostal retractions (<12 months)
- Severe difficulty breathing (≥12 months)
- Grunting
- Nasal flaring
- Apnea
- Significant shortness of breath
|
Normal feeding (infants); no vomiting | Not feeding (infants) or signs of dehydration (older children) |
Capillary refill <2 seconds | Capillary refill ≥2 seconds |