Neonatal abstinence syndrome, or NAS, describes a group or cluster of symptoms experienced by newborns exposed to drugs or other substances while in the womb. Abstinence refers to not having something. When a baby is born and suddenly stops receiving these substances, they experience withdrawal symptoms as their body adjusts. Neonatal opioid withdrawal syndrome, or NOWS, is specific to withdrawal from opioids and will not be covered in depth here, though the symptoms and treatment can be largely the same as NAS. NAS may lead to short-term problems with a baby’s stomach, intestines, and breathing, and long-term problems with their nervous system and motor abilities. According to the Agency for Healthcare Research and Quality 2021 data, the NAS rate is 6.2 per 1,000 newborn hospitalizations. Physical therapists treat infants, toddlers, and school-aged children who have experienced NAS and its longer-term symptoms in a variety of settings.

Physical therapists are movement experts. They improve quality of life through hands-on care, patient education, and prescribed movement. You can see a physical therapist directly for evaluation and treatment without a physician’s referral.* To find a physical therapist in your area, visit Find a PT.

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*A referral may still be required by your insurance policy, corporate policies, or state practice laws (some states limit the type of treatment or number of visits without a referral).

On this page

• What Is Neonatal Abstinence Syndrome?
• Signs and Symptoms
• How Is It Diagnosed?
• How Can a Physical Therapist Help?
• What Kind of Physical Therapist Do I Need?

What Is Neonatal Abstinence Syndrome?

Neonatal abstinence syndrome, or NAS, occurs after birth when a newborn infant has been exposed to toxic substances, such as cocaine, opioids, or alcohol, while in the mother’s womb. When the baby is born, the supply of these substances is cut off, and the baby experiences withdrawal. NAS may cause many medical issues that health care providers help address while the infant is still in the hospital. NAS also may lead to longer-term movement and motor planning problems that physical therapists address.

Physical therapists may treat children with NAS in the hospital (such as in the NICU), in early intervention programs (in the home or daycare setting), or outpatient physical therapy settings.

Signs and Symptoms

Infants with NAS may experience many different health and developmental problems. Early symptoms may present as soon as 24 to 48 hours after birth or may not start until several days later. The following are early symptoms of NAS:

• Fever, sweating, and difficulty maintaining normal body temperature
• Difficulty keeping a stable heart rate
• Rapid breathing and other breathing problems
• Body shakes, twitching, jitteriness, and sometimes seizures
• Fussiness and/or high-pitched and excessive crying
• Yawning and sneezing more than expected
• Stiffness in arms, legs, and/or back
• Stuffy nose or sneezing
• Vomiting or diarrhea
• Problems sucking when nursing or taking a bottle, or other feeding difficulties
• Poor weight gain
• Stomach gas and cramping
• Blotchy skin coloring
• Skin issues around the baby’s bottom
• Trouble calming and sleeping

Later signs and symptoms of NAS include:

• Delays in physical growth, like height
• Delays in the development of motor skills (the child’s ability to move, play, and interact with the environment)
• Delays in learning or social and emotional development

How Is It Diagnosed?

The medical team will diagnose NAS based on:

• A child’s symptoms
• The mother’s exposure to toxic substances
• A positive drug screen taken from the baby’s first bowel movement or urine
• A positive drug screen taken from the blood or tissue from the baby’s umbilical cord

Infants at risk of or demonstrating withdrawal symptoms are watched closely. Physicians, nurses, child-life specialists, and therapists in the hospital use one or more special tools to assess and treat infants with NAS. Common tools include:

• Modified Finnegan Neonatal Abstinence Score. This tool helps to identify the severity of NAS symptoms and guides doctors in medication management if needed.
• Eat, Sleep, Console Assessment. This tool looks at an infant's ability to eat, sleep, and be consoled. It also focuses on treatment without medications that include a low-stimulation environment, skin-to-skin contact, breastfeeding, and other, individualized methods. This tool was developed for infants with opioid exposure only.

After hospital discharge, your infant’s physical therapist will perform tests to assess your infant’s symptoms, development, and environment. They will start by gathering information about your family’s history. They may ask you questions such as:

• What are typical daily routines for you and your baby?
• What does your baby enjoy?
• What upsets your baby?
• How do you calm your baby?
• Where does your baby sleep?
• How do you hold your baby?
• How do you feed your baby?

Your child’s physical therapist may conduct a physical exam to assess the child’s:

• Readiness to play and move
• Alertness
• Stress cues
• Reflexes
• Muscle strength
• Muscle tone (tightness or floppiness)
• Head and trunk control
• Visual tracking
• Oral motor strength for sucking
• Natural movement in a variety of positions

Physical therapists also use motor tests to help assess a baby’s ability to move. These tests may include observations, physical testing, and caregiver surveys about how the child behaves when awake and sleeping.

How Can a Physical Therapist Help?

Newborns with NAS often need help from a team of health care professionals and medications. Specially-trained physical therapists are part of the medical team that treats infants with NAS in the hospital and after discharge.

Your physical therapist will use the best available evidence to help develop a treatment program for your baby’s specific needs, challenges, and goals. They will work with you to:

• Adapt your baby’s environment to promote sleep, play, eating, and bonding.
• Promote and monitor your baby’s physical and motor development.
• Support bonding with your baby.

Physical therapists who work in the hospital often support the infant and family as they leave the hospital and begin community-based services. They also work with infants and children who experience NAS after discharge to help them achieve their developmental milestones and reach their full motor and physical potential.

In the Hospital

to stay in the hospital for more than the typical night or two.

While in the hospital, a physical therapist may help to develop a care plan that:

• Protects an infant’s sleep by limiting extra handling or other unneeded disturbances.
• Educates caregivers on safe sleep practices.
• Educates caregivers about infant stress cues, which may include:
• Looking away from the observer.
• Arching the neck and back.
• Making frantic and excessive movements.
• Having frequent hiccups, sneezing, or yawning.
• Educate caregivers about ways to calm infants. These may include:
• Using a pacifier or swaddling blankets.
• Offering hands-on care (positive touch), massage, and movement experiences.
• Promoting skin-to-skin holding or holding swaddled.
• Educate caregivers on how to give baths and change diapers using a snug blanket.
• Educate caregivers how to create a low-stimulation environment for the child, including:
• Recommendations for dim lighting and a quiet room
• Assisting with developing good sleeping patterns
• Gradually introducing light, touch, sound, movement, faces, toys, and smells
• Minimize quick movements
• Help to improve food intake by strengthening the baby's ability to take a bottle or breastfeed successfully. This process may include:
• Recognizing infant sucking patterns
• Using pacifiers
• Positioning the baby properly
• Collaborating with occupational therapists, speech therapists, and lactation consultants
• Help caregivers recognize signs for when the baby is ready to play and bond. These may include:
• Looking at caregivers
• Bringing hands to mouth
• Snuggling
• Provide personalized family/caregiving education.

After Discharge From the Hospital

Infants with NAS may need extra developmental support after going home from the hospital. All babies who experience NAS qualify for early intervention services and ongoing support from a full developmental team. Early intervention programs are available in all 50 states and territories. They provide needed therapy services and support for children from birth to 3 years who have developmental delays and disabilities. These programs are free or offered at a reduced cost for eligible children. Each state defines "developmental delay" differently, and services can vary from state to state. A pediatrician or physical therapist can help parents learn what services their state offers. They also can help with the referral process.

Physical therapists are an important part of your and your child’s health care and early intervention team. Physical therapists will assess whether the child has delays in growth and motor development and help to develop specialized plans or services that address you and your child’s needs.

These specialized services may be provided in the following settings:

• Early intervention programs. Physical therapists treat young children (birth to age 3) at risk for developmental delays. In-home providers help the child reach movement milestones through playtime, parent coaching, and modifications to daily routines.
• Developmental (or neonatal) follow-up clinics. Some hospitals have programs where families return for a developmental clinic visit every few months. These clinics are usually staffed by a medical team that includes pediatric physical therapists. This helps ensure the infant reaches their developmental milestones. A referral for outpatient physical therapy or early intervention services may be made through this clinic if needed.
• Outpatient physical therapy. Infants with NAS may be referred to a pediatric clinic (one that specializes in children’s rehabilitation). Pediatric physical therapists provide personalized treatment and fun play activities for babies designed to help them progress in their development.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to evaluate, manage, and treat various symptoms and conditions. You may want to consider seeing a physical therapist who is:

• Experienced in treating babies premature to 12 months
• A board-certified clinical specialist in neonatal or pediatric physical therapy, or who has completed a residency or fellowship in neonatology or pediatric physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to your child’s condition.
• A practice that focuses on family-centered and infant developmental care

You can find physical therapists in your area with these credentials and clinical expertise through Find a PT, a tool built by the American Physical Therapy Association. General tips when you're looking for a physical therapist (or any other health care provider):

• Get recommendations from family, friends, or other health care providers.
• Ask about the physical therapists' experience in treating babies before making an appointment.
• Be prepared to describe your child’s symptoms in as much detail as possible. Make a note of what makes those symptoms worse or better.