Problem Solving: Supporting NAS infants in the NICU

Question: I work in a level 2 NICU and we are seeing a rapid increase in infants referred to us with NAS. Are there any courses on this population to help us better support them?

Infants with prenatal drug exposure are one of the challenging populations in the NICU. They often present with poor state modulation, sensory-motor disorganization, altered sensory-motor processing and postural control, and a hyperactive sucking drive which can lead to coughing/choking. Their parents are often ill-equipped to have the patience and problem-solving skills necessary to help these infants from a postural, sensory-motor and neurobehavioral perspective.  I am not aware of any courses/seminars specific to this population.

In the NICU there are many different etiologies that cross our paths. Focus on each infant’s unique history and clinical presentation to see what domains for that infant are going to get your focus. As you complete your differential on these infants, determine what areas of function are problematic and then select from the typical NICU interventions often utilized, which are based on clinical wisdom and/or research evidence. This often includes for this population with Neonatal Abstinence Syndrome: secure swaddling to provide compression and containment, facilitating flexion and midline, offering vestibular input to calm/organize, use of a slow flow nipple and co-regulated pacing to optimize coordination, and intermittently resting the infant briefly to maintain reserves and organization.

Our babies with neonatal abstinence syndrome are often term or post-term and may unfortunately be expected by caregivers to have more skill than they actually do.  In the early days/weeks of life, the implications of stressful feeding on their growing brain, and its architecture going forward, may not be appreciated. The growing body of research on neuro-protection should heighten everyone’s awareness of the importance of positive infant-guided feedings for all infants in the NICU, especially those with NAS. For more information on neuro-protection, I recently posted an article on neuro-protection on this list serve; should be in the archives.

Nurses will especially benefit from the SLP’s guidance regarding co-regulated pacing, and why the slow flow nipple is helpful, as they may unfortunately want to offer a faster flowing nipple in response to the infant’s unbridled voracious urge to suck. They may not recognize that the sucking drive for an infant with NAS is a byproduct of an altered neuro-regulatory system, not a sign of true “hunger’ much of the time.

Parent and families will benefit from anticipatory guidance (watching you feed while you describe what you are doing, why and the infant’s communication) and guided participation. They will benefit from many one-on one sessions with the SLP to help them learn to prophylactically keep the infant’s state modulation well-supported through reading the infant’s communication during feeding, understanding what the best strategies/interventions are, and when to use them, and how to support their fragile infant through an infant-guided feeding approach.

The OT in your NICU is a resource regarding sensory-motor and vestibular input. One of my goals is to publish on supporting feeding safety and success with our NAS infants to help support my colleagues; watch for that down the road :-). For now, you can find more information about NICU problem-solving and interventions through the resources on my website

I hope this helps!


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