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Developmental Care And Feeding Of Infants With Neonatal Abstinence Syndrome

Developmental Care And Feeding Of Infants With Neonatal Abstinence Syndrome
Tina Davis, OTR/L, BCP
July 12, 2023

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Editor's note: This text-based course is a transcript of the webinar, Developmental Care And Feeding Of Infants With Neonatal Abstinence Syndrome, presented by Tina Davis, OTR/L, BCP.

Learning Outcomes

  • After this course, participants will be able to compare and contrast 2 different unique feeding challenges in the infant with NAS.
  • After this course, participants will be able to analyze at least 3 strategies to promote effective state regulation.
  • After this course, participants will be able to differentiate between 3 types of appropriate assessments for this population.


I am currently working in a hospital-based outpatient setting with a great team including PT, OT, and speech. About 75% of our caseloads are in the zero to five-year age range.

We have a 50-bed, level-three NICU, and I am part of an outpatient NICU follow-up team. This team includes neonatologists, dieticians, social workers, pediatric psychologists, OT, and PT.

Case Studies

My workplace has requested that I not use photos or actual client cases, so what is being presented today are examples based on clients that we might typically treat. All photos used are my personal photos and do not represent actual patients.

Jean Piaget

Here is a quote to keep in mind during this talk. "If you follow the child…you can find out something new.”

NAS-Neonatal Abstinence Syndrome

  • Postnatal withdrawal syndrome
  • Complex disorder that primarily involves CNS, ANS, gastrointestinal system
  • Variable signs and severity
  • Dysregulatory imbalance

Neonatal abstinence syndrome (NAS) is a complex postnatal withdrawal syndrome that can occur from in-utero exposure to several substances, including heroin, prescription painkillers, and medications used to treat opioid addiction. NAS represents acute discontinuation of transplacental opioid exposure after delivery. Because opioids readily cross the placenta, the fetus can become opioid-dependent during gestation.

NAS manifests shortly after birth and rates are increasing alarmingly. There is no reliable way to predict the severity of withdrawal that will occur.

NOWS- Neonatal Opioid Withdrawal Syndrome

  • Neonatal Opioid Withdrawal Syndrome
    • The term is often used interchangeably with NAS.
    • Infants born to mothers using opioids 

Another related term is neonatal opioid withdrawal syndrome (NOWS). NOWS refers specifically to withdrawal from opioids, whether illicit or prescribed. It is sometimes used interchangeably with neonatal abstinence syndrome (NAS), but more precisely indicates withdrawal only from opioids.

The onset of clinical withdrawal signs reflects the opioid's half-life. For example, heroin withdrawal often begins within 24 hours of birth, while methadone withdrawal usually starts 24-72 hours after birth. In some cases, withdrawal can be delayed 5-7 days, even beyond hospital discharge for healthy-term infants. The literature indicates subacute opioid withdrawal signs may persist for up to 6 months.

Opioid Use Disorder-OUD

  • MMT- maternal methadone treatment
  • BMT- buprenorphine maintenance treatment
    • (Subutex)

The standard of care for opioid dependence in pregnancy is medical management with daily opioid substitution therapy. This involves prescribing methadone or buprenorphine to prevent withdrawal symptoms and drug cravings.

There are a few medication options for opioid dependence treatment during pregnancy. The most common are methadone maintenance therapy and buprenorphine maintenance therapy (often called Subutex).

These treatments reduce illicit opioid use and improve prenatal care, lowering risks of obstetric complications and preterm birth. They also reduce cravings, withdrawal symptoms, and relapse in the mother. Maternal lifestyle and illegal activities often improve as well.

However, there are still high rates of neonatal abstinence syndrome when mothers take these medications as prescribed, ranging from 40-80%. The medications prevent maternal withdrawal but still cross the placenta, causing dependence and subsequent withdrawal in the newborn after delivery.


  • 333% increase in Opioid use disorder from 1999-2014
  • 433% increase in NAS from 2004-2014
  • One birth every 25 minutes

Statistics from the American Academy of Pediatrics show a 333% increase in opioid use among pregnant women (1999-2014), and a 433% rise in neonatal abstinence syndrome (NAS) cases nationwide from 2004 to 2014. In 2012, one baby was born with NAS every 25 minutes in the United States.

  • 2010–2017
    • Opioid-related diagnoses documented at delivery increased by 131% from 2010 – 2017
  • 2020
    • The average LOS for a newborn with NAS was 9 days in 2020 compared to 2 days for other newborn hospital stays
  • 2020
    • NAS incidence ranges by state and in rural compared to urban areas in 2020

The CDC reports that opioid-related diagnoses at delivery increased by 131% from 2010 to 2017. In 2020, the average hospital stay for a typically born infant was two days, compared to nine days for an infant with NAS. NAS rates vary significantly by state and between rural versus urban settings. Hawaii sees approximately 1 in 1,000 live births affected, while West Virginia has a rate of around 43 per 1,000, according to 2020 CDC data.

Signs and Symptoms

  • Central Nervous System
    • Seizures
    • Tremors
    • High pitched cry
    • Increased muscle tone
    • Myoclonic jerks
    • Skin excoriation
    • Irritability

NAS impacts the central nervous system and gastrointestinal tract. Predominant symptoms reflect these systems. Signs typically appear within the first few days after birth, with variable timing of onset and severity not well understood. Multiple factors influence severity, including opioid type, dosage, and timing of fetal exposure. These may alter withdrawal risk.

  • Autonomic Nervous System
    • Tachypnea
    • Fever
    • Sneezing
    • Sweating
    • Frequent yawning
    • Nasal stuffiness
    • Mottling
    • Frequent yawning

Here are some autonomic nervous system symptoms when infants are withdrawing.

  • Gastrointestinal system
    • Excessive sucking
    • Loose or watery stools
    • Projectile vomiting
    • Regurgitation
    • Weight loss
    • Poor feeding

Gastrointestinal signs and symptoms from withdrawal impact feeding. GI discomfort is common. A NICU dietician colleague reports explosive, watery stools in breastfed infants that are withdrawing, contrasting with the typically seedy, loose, but not watery stools of non-withdrawing breastfed babies. This reflects the significant GI effects of neonatal abstinence syndrome.

Treatment Frequently Requires Intensive Care

Withdrawing infants can become critically ill, requiring intensive care and medication to manage symptoms. Once the medication is started, a systematic weaning process follows that often lengthens the hospital stay.

Some hospitals effectively treat these infants in newborn nurseries or step-down units. Rooming-in is best practice when available, feasible primarily in single-family rooms in the NICU or step-down units.

A key treatment goal is strengthening the infant-mother bond. A recent meta-analysis found rooming-in lowered rates of withdrawal symptoms and medication needs.

Unfortunately, many infants require medication assistance for withdrawal. Treated infants may exhibit increased arousal, hypertonicity, and excitability.

Pharmacological Treatment

For pharmacological treatment, approximately 72% of NICUs use morphine as the first line, while 15% use methadone. Other secondary medications include clonidine, phenobarbital, Valium, and Subutex. The decision to medicate withdrawing infants is based on assessment using a validated scoring system. These tools quantify the severity of withdrawal signs to guide treatment needs.

Modified Finnegan Neonatal Abstinence Score

  • CNS Disturbances
  • Metabolism, Respiratory, and Vasomotor Disturbances
  • Gastrointestinal Disturbances

The Modified Finnegan Neonatal Abstinence Score is the most common tool used to assess withdrawal severity. Recommended since the 1970s, it is considered best practice for NAS monitoring. This validated tool for full-term infants is endorsed by the American Academy of Pediatrics. It scores 21 items in three categories: central nervous system, autonomic nervous system, and gastrointestinal symptoms.

One limitation is the potential for inconsistent scoring and management due to inadequate caregiver training. Scoring is usually completed by nursing staff when NAS is suspected based on maternal history or a positive toxicology screen. Another downfall is the focus on specific symptoms rather than infant abilities. One doctor described switching units to a different scoring system because the Finnegan didn't adequately account for infant abilities to guide medication needs. For example, the scoring difference between yawning/sneezing 2 times versus 3-4 times in a period could determine whether medication is administered.

Scoring Management

Scoring begins within 24 hours of birth. Pharmacological treatment is initiated if an infant scores 12 or higher for two consecutive periods, or 8 or higher for three consecutive scoring periods. Otherwise, symptoms are monitored approximately every 3-4 hours.

Non-pharmacological Treatment

  • Shown to decrease:
    • need for advanced medications
    • length of stay
  • Shown to increase:
    • breastfeeding initiation rates

The American Academy of Pediatrics recommends non-pharmacological care as first-line treatment for NAS. This decreases medication needs, and length of stay, and increases breastfeeding rates. Recommended methods to reduce withdrawal symptoms without medication include:

  • Decreasing environmental stimuli
  • Tight swaddling and optimal positioning (side or back in a C-curve, chin-tucked)
  • Applying deep pressure over the head and body for self-calming
  • Clustering care with gentle handling
  • Offering non-nutritive-sucking opportunities
  • Small, frequent feedings with hyper-caloric formula if needed
  • Encouraging breastfeeding when possible

Many of these techniques align with occupational therapy interventions.

Eat, Sleep, Console Method

  • Eat- able to breastfeed or take at least 1 oz from a bottle per feed
  • Sleep- sleep undisturbed for at least 1 hour
  • Console- if crying, but consoled within 10 minutes

The Eat, Sleep, Console method is a newer, more functional approach to assessing withdrawal severity. It focuses on infant abilities rather than just symptoms. Morphine is not administered or increased if the infant can:

  • Eat/breastfeed at least 1 ounce per feeding
  • Sleep undisturbed for at least 1 hour
  • Be consoled within 10 minutes if crying

This approach significantly reduces the length of stay, medication use, and costs. However, it requires full unit buy-in and culture change.

4 Behavioral Domains

State control and attention

Motor and tone control

Sensory Processing

Autonomic control


Poor focusing and gaze aversion

Poor self calming

Decreased calm/ alert state




Increased and   poorly controlled  movements








GI dysfunction


Skin changes



Withdrawing infants often struggle to self-regulate and control arousal states. This critical skill impacts all areas of development and caregiver response. Dysregulation in one area influences others. For example, an irritable, hypersensitive infant with poor self-calming may be perceived as hungry, leading to atypical feeding patterns. Or a hypotonic, sleepy infant unable to sustain calm alertness may exhibit unclear feeding cues and inadequate intake. GI problems can also disrupt feeding drive and calorie consumption, further impacting growth and feeding behavior.

The interrelationship between state regulation, feeding, and other domains highlights the importance of supporting functional regulation skills in withdrawing infants. Occupational therapists can play a key role in this area.

Infant Sleep Wake Cycles

  • Quiet Sleep
  • Active sleep
  • Drowsy
  • Quiet alert
  • Active alert
  • Crying

All infants naturally cycle through sleep/wake states throughout the day. Typically this occurs seamlessly. However, infants affected by in-utero exposures often have difficulty moving between states and achieving quiet alertness. Achieving an organized, quiet alert state is important for optimal functioning across all areas of infant development.

Occupational Therapy

A key occupational therapy role is teaching caregivers how to support infants in smoothly transitioning between states. Using our sensory lens, we promote calming techniques while reducing extra or stressful stimulation. Facilitating an organized, quiet alert state is important, as is helping infants return to quiet sleep.

Mothers with opioid use disorders often exhibit increased stimulation like frequent touching, kissing, or tickling. Teaching responsive calming versus overstimulation is critical, as is helping caregivers recognize infant stress cues. Supporting this early bonding while ensuring a soothing environment enables infants to better regulate states.

Educating caregivers on reading cues and using calming strategies is an OT priority. Withdrawal interferes with occupational performance in areas like feeding and ADLs. Our expertise in infant development, positioning, sensory processing, and behavior states is an important contribution to the care team.

Evidence-Based Practice

  • Trauma-informed
  • Strengths-based
  • Family-Centered
  • Supportive
  • Non-judgmental educational model
  • Developmental neuroprotective care

Educating and coaching caregivers is critical, as withdrawing infants have unique feeding challenges described in OT literature. A 2022 AJOT article entitled “Feeding Infants Born Substance Exposed: A Sensory-Based, Family-Centered Approach” provides excellent guidance. Additionally, many mothers with opioid use disorders have trauma histories. Using trauma-informed, strength-based approaches is key. As one mother stated, “Here, you don’t feel the stigma that comes with addiction. I didn’t wanna go anywhere at first.” Non-judgmental, educational methods help build family partnerships.

Developmental neuroprotective care is another evidence-based approach incorporating:

  • Calming environment
  • Safe, effective sleep
  • Soothing tactile/proprioceptive input
  • Maximizing feeding success to support bonding

This aligns well with occupational therapy’s holistic perspective.

Case Study- David

David exhibited NAS symptoms within 24 hours of birth. He required a 15-day NICU stay and morphine treatment for withdrawal management.

Occupational Profile

  • Strengths of strong family support of a maternal grandmother
  • Challenges of feeding difficulties, tremors, poor state control, increased muscle tone

David was cared for by his maternal grandmother after NICU discharge. He exhibited ongoing GI issues including frequent emesis, stooling, and severe diaper rash. He was irritable and described as a frantic feeder. For the purposes of this case study, we will focus on David's feeding challenges.

Frantic Feeding

  • Sensory Based Recommendations
    • Reduce overall stimuli
    • Rhythmic rocking – 1 rock per second during feed

Frantic feeding involves high arousal, ballistic movements, irritability, and difficulty calming to a quiet alert state needed for feeding. Poor oral motor coordination and increased calorie needs often lead to hyperphagia, or excessive eating, in these infants.

Typically, newborns eat every 2-4 hours based on hunger cues. Withdrawing infants exhibit unclear cues and may need more frequent, smaller feeds. Recommended strategies include decreasing stimulation with quiet, calm settings, managing reflux and nutritional needs with more frequent smaller volumes, and meeting the need for non-nutritive sucking. Rhythmic rocking timed with suck-swallow-breath coordination can facilitate optimal feeding pacing.

Reading Infant Cues

  • Feeding Readiness Cues
    • Rooting
    • Hands to mouth
    • Lip smacking
  • Stress Cues
    • Finger splaying
    • Fisted hands
    • Hiccups
  • Self Soothing Behaviors
    • Sucking
    • Hands to mouth
    • Grasping and holding

In outpatient follow-up, caregivers often accurately read infant feeding cues initially. When asked how their baby shows hunger, they describe rooting, mouthing, lip smacking, noises, or crying. However, they may be less attuned to stress cues beyond crying. Educating on reading body language for both hunger and stress is key. This helps caregivers know when feeding is indicated versus utilizing other calming strategies for irritable behavior. It's important to explain how GI symptoms or general dysregulation can obscure hunger signals over time. Establishing consistent, predictable routines centered around the infant's needs fosters successful, infant-led feeding interactions. This sets them up for positive experiences.

Strategies for State Regulation

    •   Sensory Stimulation Techniques
    •   Calming Techniques
    •   Positioning
    •   Low Stimulation Environment
    •   Parent/Caregiver Bonding
    •   Infant Massage
    •   Developmental Facilitation

Achieving and maintaining a calm alert state helps infants exhibit clear hunger cues. Sensory-motor strategies like non-nutritive sucking and swaddling can promote regulation prior to feeding. For oral motor coordination, upright midline positioning with chin tuck is recommended, along with left sidelying. Low stimulation techniques include reduced lighting/sounds and responding quickly at the first signs of fussiness before escalation. Vertical rocking or patting is often preferred to side-to-side swaying. Infant massage and skin contact also help prepare for feeding.

In utero substance exposure often leads to low birth weight and prematurity. Early oral motor skills are frequently disorganized and sucking uncoordinated. Hyperphagia is common. Increasing formula caloric density around day 3 is typical, along with specialty formulas. For breastfed babies, adding human milk fortifier boosts calories to meet higher metabolic needs.

Establishing regulation and supporting infant readiness before feeding facilitates successful occupations. Occupational therapists can provide essential education and strategies to caregivers on reading infant cues, achieving calm alertness, and setting up an optimal feeding environment.

Growth Difficulties

  • Smaller size at birth
  • Increased metabolic demand
  • Lower growth velocity
  • Poor feeding
  • Gastrointestinal symptoms

Growth difficulties may persist for years, but typically infants catch up around 4 months and have fully caught up by 2-3 years. Infants innately regulate caloric intake. However, parental feeding practices can alter eating behaviors and affect weight gain and growth. Occupational therapists play an important role in educating caregivers on responsive, infant-led feeding approaches to support healthy development.

GI and Feeding Difficulties

  • Regurgitation
  • Gastroesophageal reflux
  • Nausea
  • Emesis
  • Delayed evacuation
  • Poor weight gain
  • Uncoordinated and repetitive sucking

Successful feeding requires integrating skills across multiple systems and adjusting for comorbidities. Infants diagnosed with NAS have a much higher rate of feeding difficulties than non-exposed infants (18.1% vs 3%). They demonstrate different feeding patterns and may struggle with exhibiting feeding readiness behaviors. Early challenges often persist, making post-discharge monitoring and follow-up essential for this population. As experts in infant feeding and development, occupational therapists play a critical role in assessing feeding skills and educating caregivers to foster healthy, successful feeding experiences.


  • Safe and encouraged in many cases
  • Policies and guidelines
  • May reduce clinic signs and symptoms
  • May reduce the length of stay

Breastfeeding is one of the most studied non-pharmacological interventions for NAS. Guidelines suggest encouraging breastfeeding if the mother has not relapsed in over 90 days, but discouraging it within 30 days of relapse. Overall, breastfeeding is safe for mothers medically taking methadone or Subutex. It may reduce withdrawal signs and length of stay. Caution is needed if breastfeeding is suddenly discontinued, as some infant withdrawal signs have been reported. Occupational therapists play a key role in supporting breastfeeding dyads impacted by NAS through education, guidance, and promoting a positive feeding relationship.

Problematic Feeding Problems

  • Sucking
  • Breathing coordination
  • Feeding efficiency
  • Disruptive behaviors
  • Higher arousal

Withdrawing infants exhibit problematic feeding patterns like poor suck-swallow-breath coordination and inefficiency. Behaviors may include refusing breast/bottle, coughing, irritability, inability to self-calm, hyperarousal, and increased fussiness during feeds. Adequately managing withdrawal signs through positioning, comfort techniques like rocking, and slower flow nipples to pace the feed can facilitate safety and success.

Treating complex infant feeding issues requires advanced skills and training. Excellent resources exist through AOTA, therapy education companies, and well-known feeding experts and authors. Targeted continuing education optimizes our ability to help infants and families impacted by substance exposure and NAS. As occupational therapists develop specialized expertise, we can play an invaluable role in supporting healthy development and participation in feeding occupations.

Case Study- James

Occupational Profile

  • Strengths of interactive when quiet/alert
  • Challenges of difficulty with state control, sleeping, feeding, low muscle tone

James was a 2-month-old seen initially in outpatient follow-up. He lived with his grandmother, who was concerned about his feeding difficulties and challenges with state regulation, specifically achieving and maintaining calm alertness.

James displayed lower muscle tone and was often quite sleepy, struggling to reach quiet alertness. He would quickly cycle from deep sleep to irritable alertness. His grandmother often perceived his cues as hunger and offered a bottle, but he would latch, suck briefly, then return to deep sleep.

Though interactive when able to reach quiet alertness, James’s primary challenges involved state regulation for feeding and difficulty maintaining an optimal level of arousal for eating. As occupational therapists, we can provide essential education and strategies to support caregivers in reading infant cues, managing state, and facilitating successful feeding occupations.

Sleepy Feeding

  • Sensory based recommendations
    • Alerting methods
    • Tactile stim
    • Rocking or patting in an arrhythmic pattern

James demonstrated a feeding pattern described in the literature as "sleepy feeding." He had difficulty managing formula flow and often choked, becoming uncomfortable and dysregulated initially before shutting down into deep sleep. Yet he would wake screaming when the bottle was removed.

To promote safety and success, we trialed slower flow nipples to control the pace. Swaddling, chin tuck positioning, and sidelying also optimized flow control. Helping James reach calm alertness before feeding was essential, as his grandmother was often feeding for comfort versus hunger cues.

After several sessions targeting regulation, positioning, and responsive feeding, his grandmother observed she had been feeding before he was ready. Supporting her understanding of infant cues, arousal, and readiness facilitated more successful feeding occupations. Occupational therapy plays a vital role in educating caregivers, modifying feeding methods, and building healthy infant feeding experiences.

Long Term Developmental Outcomes

  • Motor
  • Cognitive
  • Language
  • Emotional/ behavioral dysregulation 

Feeding is not the only concern with withdrawing infants. CNS effects can persist for 4-6 months, making specialist follow-up and early intervention essential.

Studies show higher rates of developmental difficulties. Preschoolers have increased risks for cognitive, psychomotor, attention, and socioemotional problems. They score lower on academic achievement tests.

Careful monitoring and assessment for neurodevelopmental issues from birth is recommended, along with support across the transition to school. Early detection enables early intervention, which is key for optimal outcomes. Occupational therapists play a vital role on the care team in supporting neurodevelopment, sensory processing, motor skills, regulation, feeding, and achievement of developmental milestones.

Preterm and Newborn Assessments

  • General Movements Assessment
  • Hammersmith Infant Neurological Exam
  • Assessment of Preterm Infant Behavior
  • Neonatal Behavioral Assessment Scale
  • Test of Infant Motor Performance

Assessment is an important component of occupational therapy with withdrawing infants. Common tools used in the NICU and follow-up clinics include the NICU Network Neurobehavioral Scale, Newborn Behavioral Observations, and Assessment of Preterm Infant Behavior. These require administration in calm alertness, which can be challenging in outpatient settings.

Additional assessments that are more feasible for community or home-based early intervention will be discussed next. Thorough evaluation enables occupational therapists to identify needs, track progress, and provide targeted, evidence-based intervention to support optimal development.

DAYC-2 Developmental Assessment of Young Children

  • Good choice for telehealth, home health
    • Birth-6 years
    • Looks at 5 domains
    • Natural environment

The DAYC-2 is a commonly used early intervention assessment since it utilizes natural environment materials. This makes it well-suited to home health and telehealth for children birth to 5 years. It examines five domains - cognition, communication, social-emotional development, physical development, and adaptive behavior.

These domains align with mandated assessment and intervention areas for young children under the Individuals with Disabilities Education Act (IDEA). The DAYC-2 provides valuable information to guide occupational therapy treatment planning and collaboration with early intervention teams.

HELP (Hawaii Early Learning Profile)

  • Birth-3
  • 6 Developmental categories
  • Clear picture development and progress
  • Facilitates communication and collaboration with parents

The Hawaii Early Learning Profile is another useful early intervention assessment for ages birth to 3 years. It is criterion-referenced, measuring performance on specific concepts and skills through caregiver interviews, observation, and play interactions. Six domains are addressed - cognitive, language, gross motor, fine motor, social-emotional, and self-help. This family-centered tool facilitates communication with caregivers and provides a comprehensive picture of development to guide occupational therapy intervention. As a criterion-referenced measure, it tracks children's progress in acquiring specific developmental skills.

Infant Toddler Sensory Profile 2

  • Birth-36 months
  • Evaluates sensory processing patterns and abilities
  • Caregiver questionnaire

The Infant Toddler Sensory Profile 2 includes an infant form (birth to 6 months) and a toddler form (7-35 months). These caregiver questionnaires evaluate sensory processing patterns and abilities. Short and easy to administer, they are also available in Spanish. As a focused sensory assessment, the Infant Toddler Sensory Profile 2 provides occupational therapists with valuable insight into an infant's sensory responses and modulation. This supports targeted sensory-based intervention to facilitate regulation and functional performance.

Peabody Developmental Motor Scales- 2nd Edition

  • Birth-5 years
  • Assesses fine and gross motor skills
  • 6 Subtests

The Peabody Developmental Motor Scales, Second Edition (PDMS-2) is a commonly used assessment in outpatient settings. It examines fine and gross motor skills through six subtests: reflexes, stationary, locomotion, object manipulation, grasping, and visual-motor integration. It provides standard scores, percentile ranks, and age equivalents. As a norm-referenced test, the PDMS-2 allows occupational therapists to pinpoint motor delays and track progress over time. The detailed motor analysis guides targeted intervention to advance motor skills in infants and young children.

Bayley Scales of Infant and Toddler Development Fourth Edition

  • Birth-42 months
  • Evaluates 5 major areas

The Bayley Scales of Infant and Toddler Development, Fourth Edition (Bayley-4) is commonly used in outpatient facilities. It includes social-emotional and adaptive behavior caregiver questionnaires. Unlike the previous edition, emerging skills now receive partial credit during scoring. The domains are administered efficiently and are typically well-tolerated. Results include subtest scaled scores, composite scores, percentage ranks, and age equivalents. A limitation is that it does not account for movement quality, which therapists should document separately. Overall, the Bayley-4 provides comprehensive, norm-referenced data to identify developmental delays, guide treatment, and demonstrate progress. It is a valuable occupational therapy assessment tool for infants and young children.

Visual Difficulties

  • Reduced visual acuity
  • Nystagmus
  • Delayed visual maturation
  • Strabismus
  • Refractive errors
  • Cortical visual impairment

Visual difficulties are more prevalent in infants with NAS. One study found 8% were treated for strabismus by age 3. In utero opioid exposure can impact the development of the visual cortex, increasing risks for adverse outcomes. While unclear if pharmacological treatment further increases risks, one study did find higher rates of nystagmus in treated infants.

As visual skills are critical for development, occupational therapists should screen for visual deficits and collaborate with ophthalmology as needed. Supporting visual function helps strengthen occupational performance and participation.


  • Higher incidence
  • More likely right sided than left

Infants with NAS demonstrate abnormal movement patterns and hypertonicity requiring more swaddling and containment. This, along with increased hospital stays, creates a multifactorial risk for torticollis. Rates are elevated, persisting at 24 months. One study found 24.9% of NAS infants followed up were diagnosed with torticollis, versus 16% in the general population. Of these cases, 84% had right-sided torticollis. Plagiocephaly is also more prevalent, affecting 57% of infants with torticollis in this sample.

Careful monitoring and individualized treatment plans are essential to address positioning and tone abnormalities. As experts in infant development, movement, and tone, occupational therapists play a key role in early detection and intervention for torticollis and plagiocephaly. This optimizes development and participation.

Case Study- Sierra

Sierra's case involved morphine initiation in the newborn nursery with transfer to the NICU on day 1 for escalating NAS scores. She received 12 days of morphine treatment and had an 18-day hospital stay. At discharge, she went home with her mother, who was in treatment, and her father.

Occupational Profile

  • Strengths of maternal-infant bond
  • Breastfeeding success
  • Challenges of torticollis, increased tone

Sierra demonstrated strengths in the maternal-infant bond and successful breastfeeding. Challenges involved increased muscle tone and torticollis. She initially had outpatient therapy targeting tone and torticollis. At 6 months, Sierra’s mother raised new concerns about introducing complementary foods.

Positioning Support

When Sierra became fussy during feeding, her mother perceived it as a desire for more food and offered bites more quickly. However, Sierra was not exhibiting clear hunger cues or opening her mouth for the spoon. We discussed reading her signals and trying a break to determine if the fussiness indicated a need to pause versus feed more.

Educating caregivers on infant feeding cues is key. Effective positioning techniques also support success. With challenges like torticollis, vision issues, and dysregulated feeding, appropriate postural support is essential.

Recommendations include tummy time when awake and playing, working up to short bursts totaling around 90 minutes/day. Swaddling and containment help regulate states. Positioning minimizes disruptive feeding patterns. While medical positioning devices are available, education on using household items in the natural environment is ideal.

Occupational therapists are uniquely skilled at analyzing factors impacting feeding and play. We can provide caregiver education and environmental modifications to facilitate occupational performance and participation.

Caregiver Education

  • Infant Cues
  • Safe Sleep
  • Feeding Recommendations
  • Developmental Stimulation
  • Sensory Stimulation
  • Environmental Modifications
  • Infant Massage and Positioning

Caregiver education is essential, with the goal of supporting the maternal-infant dyad. Actively engaging all family members is key. Open-ended questions facilitate thoughtful conversation and collaboration:

  • Is it okay if I watch you feed him so I can see how he sucks?
  • What if I try feeding him to get a sense of it myself?
  • What is she really good at?
  • Tell me what happens with tummy time.
  • I'm curious whether a sidelying position could help.
  • How does he show you he's finished eating?

Asking for caregivers' perspectives, observations, and insights builds rapport. It demonstrates your interest in understanding the whole picture versus just your clinical observations. A family-centered, strength-based approach enables occupational therapists to provide targeted education and intervention tailored to each unique child within their family context.

Evidence-based Interventions for the First Year

    • Strong Evidence
      • Massage to increase self-regulation
      • Parent Training Programs
    • Moderate Evidence
      • Skin-to-skin contact
      • Kangaroo Care
      • Massage to reduce parental stress

Reviewing mental health outcomes, the strongest evidence supports:

  • Parent training programs to improve parenting behaviors
  • Massage to increase infant self-regulation
  • Clinic and home-based parent training on infant behavior and parent-child interactions, which improved parental responsiveness
  • Cue-based parenting education to enhance relationship quality
  • Mother-infant interventions focused on cue sensitivity, distress response, and social-emotional growth
  • Programs fostering infant self-regulation and cue awareness to increase maternal sensitivity and responsiveness

Moderate evidence supports:

  • Massage to reduce parental stress and increase social behavior
  • Skin-to-skin contact for maternal stress, anxiety, and attachment

Occupational therapy’s expertise in infant development, sensory processing, and parent education enables us to implement evidence-based interventions promoting healthy regulation and family relationships.


This video shows an infant eagerly and independently self-feeding. This infant's drive, enjoyment, and clear communication exemplify the feeding success we aim to facilitate through family education and intervention.

Video of child eating


Caring for infants with NAS requires an individualized, family-centered approach following the child's cues. Evidence supports interventions like parent training, massage, skin-to-skin contact, and responsive parenting education to facilitate self-regulation and feeding. Thank you for your time today!

Questions and Answers

If the mom is using substances, doesn't it come through the breast milk?

Research shows some amount of methadone or Subutex taken medically can pass into breastmilk. It's important to closely monitor infants and not abruptly stop breastfeeding, as this could cause withdrawal signs.

Are there any strategies you recommend for infants who don't respond to massage yet are unable to calm with vestibular and deep pressure input?

This is challenging. First ensure basic needs are met around sleep, hunger, and GI comfort. Tight swaddling and putting them safely in the crib can help overstimulated infants. For significant dysregulation, they may need help calming. Persistent difficulties warrant medical evaluation.

Why is right torticollis more common in infants with NAS?

The cause is unclear. One theory is our right-handed world leads caregivers to hold infants to the right more often. More research is needed on this finding.

Do we need to report suspected parental substance use relapse when working with these families?

Any suspected child abuse or neglect must be reported. A parental relapse alone may not rise to this threshold. Focus on the infant's care and safety.


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Davis, T. (2023). Developmental care and feeding of infants with neonatal abstinence syndrome. OccupationalTherapy.com, Article 5618. Available at www.occupationaltherapy.com

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tina davis

Tina Davis, OTR/L, BCP

Tina Davis is a board-certified pediatric occupational therapist with over 30 years of experience. She is committed to lifelong learning and passionate about the ultimate goal of OT - Achieving health, well-being, and participation in life through engagement in occupation. 

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