Intercostal retractions are visible inward pulling of the skin between the ribs during breathing. They signal that someone is working harder than normal to get air into their lungs, and they’re one of the most recognizable signs of respiratory distress. If you can see the outline of the ribs sinking inward with each breath, that’s a retraction.
This happens when the airways are partially blocked or narrowed. The lungs have to generate more suction to pull air in, and that extra negative pressure inside the chest literally tugs the soft tissue between the ribs inward. It’s not a disease on its own but a visible symptom that something is making breathing difficult.
Why the Skin Pulls Inward
During normal breathing, your diaphragm contracts and drops downward, expanding the chest cavity. This creates a slight drop in pressure inside the chest compared to the air outside, and air flows in naturally. The pressure difference is small enough that the soft tissue between your ribs stays put.
When the airways are narrowed or blocked, the diaphragm and surrounding muscles have to work much harder to pull air through the obstruction. This generates a much larger drop in pressure inside the chest. That intensified suction pulls the flexible skin and tissue between the ribs visibly inward with each inhale. The same force can also pull in the skin above the collarbones or below the ribcage, depending on how severe the obstruction is.
Where Retractions Appear on the Body
Retractions can show up in several locations, and each spot tells something about how hard the body is working to breathe:
- Intercostal: Between the ribs. This is the most commonly recognized type and indicates moderate breathing difficulty.
- Subcostal: Below the ribcage, near the bottom edge of the ribs. Often seen alongside intercostal retractions in children with lower airway problems like bronchiolitis or pneumonia.
- Supraclavicular: Above the collarbones, in the soft dip at the base of the neck. This suggests more significant airway obstruction.
- Suprasternal: At the notch at the top of the breastbone. Often associated with upper airway obstruction.
When retractions appear in multiple locations at once, it generally indicates more severe distress than retractions in just one area.
Common Causes
Anything that narrows or blocks the airways can cause intercostal retractions. The most frequent triggers differ somewhat between children and adults.
In children and infants, the most common causes are viral respiratory infections like RSV (respiratory syncytial virus), croup (which causes swelling in the upper airway and a barking cough), bronchiolitis (swelling in the smallest airways of the lungs), pneumonia, and asthma attacks. Newborns can develop retractions from respiratory distress syndrome, a condition where the lungs haven’t fully matured. A foreign object lodged in the airway is another possibility, particularly in toddlers.
In adults, asthma attacks and COPD flare-ups are the leading causes. Pneumonia, COVID-19, severe allergic reactions (anaphylaxis), and airway tumors or thick mucus plugs can also produce them. Vocal cord paralysis is a less common but recognized cause.
Why Infants and Young Children Are More Vulnerable
Retractions are more common and more noticeable in babies and young children for a straightforward anatomical reason: their chest walls are much more flexible than an adult’s. An adult’s rib cage is relatively rigid, so it resists being pulled inward even when chest pressure drops significantly. An infant’s chest wall is soft and compliant, so it caves in more easily under the same pressure changes.
This increased chest wall compliance also makes retractions a more sensitive early warning sign in young children. A baby’s ribs may visibly retract with levels of airway resistance that wouldn’t produce any visible change in an adult. That’s why pediatricians pay close attention to even mild retractions in infants.
Other Signs That Accompany Retractions
Intercostal retractions rarely appear in isolation. They typically show up alongside a cluster of other signs that together paint a picture of respiratory distress:
- Nasal flaring: The nostrils widen with each breath as the body tries to take in more air.
- Fast breathing (tachypnea): The breathing rate increases as the body compensates for reduced airflow.
- Noisy breathing: Wheezing, stridor (a high-pitched sound on inhaling), or grunting may be audible.
- Restlessness or confusion: Agitation can be an early sign that the brain isn’t getting enough oxygen. Increasing confusion or drowsiness is a more serious warning.
- Difficulty speaking: Needing to pause for breath mid-sentence or being unable to speak in full sentences.
- Tripod positioning: Sitting upright and leaning forward with hands on the knees, which helps expand the lungs.
- Bluish skin color: A bluish tint around the lips, fingertips, or nail beds is a late sign that oxygen levels have dropped significantly.
Fast heart rate often accompanies these signs as the heart works harder to circulate whatever oxygen is available.
How Severity Is Assessed
Clinicians gauge severity partly by looking at how deep and widespread the retractions are. Mild retractions may be barely visible, appearing as a subtle inward tug between the ribs only during harder breaths. Moderate retractions are clearly visible with each breath. Severe retractions are deep, involve multiple locations on the chest, and are often accompanied by grunting or see-saw breathing, where the chest sinks inward while the abdomen pushes outward (the opposite of normal breathing mechanics).
In newborns, scoring systems assign points based on whether upper chest retractions, lower chest retractions, and retractions near the bottom of the breastbone are absent, just visible, or marked. A combined score above 6 on these scales points toward impending respiratory failure. While you won’t be calculating these scores at home, understanding the general principle is useful: the more locations affected and the deeper the pulling, the more urgent the situation.
What Retractions Look Like in Practice
If you’re checking a child or adult for retractions, remove or lift the shirt so you can see the bare chest. Watch from the front and the side. During normal breathing, the chest and abdomen should rise together smoothly. With retractions, you’ll see the spaces between the ribs sink inward each time the person breathes in, then return to normal on the exhale. In more severe cases, the skin above the collarbones and below the rib cage will also pull inward, and you may notice the chest and abdomen moving in opposite directions.
In infants, retractions can be subtle because the spaces between the ribs are small. Look carefully at the lower chest and the area just below the breastbone. Grunting sounds on exhale, combined with even mild retractions, are a significant finding in a baby.
Intercostal retractions are always a sign that the body is struggling to move air. Whether the cause is a treatable infection like croup, an asthma flare-up, or something more serious like anaphylaxis, visible retractions mean the person needs prompt medical evaluation to identify and address the underlying problem.