For Healthcare Professionals:

 Guidelines on Prevention of and

 Response to Infant Abductions

 Ninth Edition

 2009

®
THE “TYPICAL” ABDUCTOR

(Developed from an analysis of 256 cases occurring 1983-2008.)

1.	 Female of “childbearing” age (range now 12 to 53), often overweight.

2.	 Most likely compulsive; most often relies on manipulation, lying, and deception.

 3. Frequently indicates she has lost a baby or is incapable of having one.

4.	 Often married or cohabitating; companion’s desire for a child or the abductor’s desire to

provide her companion with “his” child may be the motivation for the abduction.

 5. Usually lives in the community where the abduction takes place.

 6. Frequently initially visits nursery and maternity units at more than one healthcare facility prior to the abduction; asks detailed questions about procedures and the maternity floor

layout; frequently uses a fire-exit stairwell for her escape; and may also try to abduct from

the home setting.

7.	 Usually plans the abduction, but does not necessarily target a specific infant; frequently

seizes any opportunity present.

 8. Frequently impersonates a nurse or other allied healthcare personnel.

9.	 Often becomes familiar with healthcare staff members, staff members work routines, and

victim parents.

10. Demonstrates a capability to provide “good” care to the baby once the abduction occurs.

In addition an abductor who abducts from the home setting

11. Is more likely to be single while claiming to have a partner.

12.	 Often targets a mother whom she may find by visiting healthcare facilities and tries to 

meet the target family.

13.	 Often both plans the abduction and brings a weapon, although the weapon may not be used.

14.	 Often impersonates a healthcare or social-services professional when visiting the home.

There is no guarantee an infant abductor will fit this description.

Prevention is the best defense against infant abductions.

Know whom to look for and that person’s mode of operation.

To receive free technical assistance by telephone or on-site and a complimentary copy of

For Healthcare Professionals:

Guidelines on Prevention of and Response to Infant Abductions,

please call the National Center for Missing & Exploited Children at

1-800-THE-LOST®

(1-800-843-5678)

Please post this flier out of view of the public at the nurses’ station,

nurses’ lounge, medication room, security office, and risk-management unit.
For Healthcare Professionals:

Guidelines on Prevention of and

Response to Infant Abductions

Ninth Edition

2009

John B. Rabun, Jr., ACSW

Executive Vice President and Chief Operating Officer

National Center for Missing & Exploited Children®

Copyright © 1989, 1991, 1992, 1993, 1996, 1998, 2000, 2003, 2005, and 2009

National Center for Missing & Exploited Children.

All rights reserved.

This information is intended solely to provide general,

summary information and is not intended as legal or security advice

applicable to specific matters.

National Center for Missing & Exploited Children®, 1-800-THE-LOST®, and CyberTipline®

are registered service marks of the National Center for Missing & Exploited Children.

Charles B. Wang International Children’s Building

699 Prince Street

Alexandria, Virginia 22314-3175

1-800-THE-LOST (1-800-843-5678)

www.missingkids.com
ii - For Healthcare Professionals
For Healthcare Professionals - iii

Contents

Acknowledgments.....v

A Message to the Reader.....vii

1. The Problem.....1

2.	 The Offender and Modes of Operation.....5

3. Guidelines for Healthcare Professionals.....9

3-1 General.....9

3-2 Proactive Measures.....12

3-3 Physical-Security Safeguards.....20

3-4 Critical-Incident-Response Plan.....24

 General Guidelines.....24

 Nursing Guidelines.....27

 Security Guidelines.....31

 Law-Enforcement Guidelines.....32

 Public-Relations Guidelines.....34

4. Liability.....41

5.	 After Discharge/Transfer from a Maternal-Child-Care Unit.....43

Special-Care Nurseries.....45

Pediatric Units.....46

Outpatient Areas.....48

Homes.....48

6. What Parents Need to Know.....51

7. Self-Assessment for Healthcare Facilities.....59

8. Bibliography.....77
ii - For Healthcare Professionals
For Healthcare Professionals - v

Acknowledgments

The National Center for Missing & Exploited Children is indebted to the belownoted individuals — without whose knowledge, expertise, original contributions

to and/or review of this ninth edition would not have been possible. For ease of use

by healthcare professionals, contributors are listed in groupings per professional 

roles. Note: Additional individuals have been so acknowledged for their contributions to the previous editions.

HEALTHCARE SECURITY AND SAFETY

Russell Colling, CHPA, CPP, Consultant, Colling & Kramer Healthcare

 Security Consultants, Salida, Colorado

Jim Crumbley, CPP, PPS, J Crumbley Associates, Lawrenceville, Georgia

	 William A. Farnsworth, CHPA, Director, Safety and Security, St. Vincent’s

 Medical Center, (Retired), Jacksonville, Florida

Linda M. Glasson, CHPA, Healthcare Security Consultant, Williams- 

 burg, Virginia

	 Paul D. Lockwood, CPP, Director of Security, Thomas Jefferson Foundation,

	 	 Monticello, Charlottesville, Virginia, Special Security Consultant to NCMEC

Bonnie S. Michelman, CPP, CHPA, Director, Police and Security and Outside

	 	 Services, Massachusetts General Hospital, Boston, Massachusetts

Fredrick G. Roll, MA, CHPA-F, CPP, President, Healthcare Security Consultants, Inc., Fredrick, Colorado

David Sowter, President, National (United Kingdom) Association

 for Healthcare Security, and Trust Security Risk Manager,

 Hammersmith Hospitals NHS Trust, London (Retired), Esher,

 Surrey, United Kingdom

NURSING

Ann Wolbert Burgess, RN, DNSc, Professor of Psychiatric Nursing,

	 	 Boston College School of Nursing, Boston, Massachusetts

Nancy Chambers, RN, BSN, Nurse Manager, Maternal Newborn Unit,

 Intermountain Healthcare, LDS Hospital, Salt Lake City, Utah

	Robert E. Emerson, RNC-NIC, IBCLC, MSN, Maternal Child Health Staff

Nurse, Southern Maryland Hospital Center, Clinton, Maryland

Connie Blackburn Furrh, RN, Vice President, Risk Management,

	 	 Cimarron Insurance Exchange, Oklahoma City, Oklahoma

LAW ENFORCEMENT

William Hagmaier, Unit Chief, National Center for the Analysis of Violent

 Crime (NCAVC), FBI Academy (Retired), Fredericksburg, Virginia

Kenneth V. Lanning, Supervisory Special Agent, NCAVC, FBI Academy

 (Retired), Fredericksburg, Virginia

	 Lee Reed, Detective, Youth Division,Abilene (Texas) Police Department (Retired)
PEDIATRICS

Daniel D. Broughton, MD, Department of Community Pediatrics,

 The Mayo Clinic, Rochester, Minnesota

Sharon W. Cooper, MD, FAAP, University of North Carolina, Chapel Hill

	 	 Developmental and Forensic Pediatrics, PA, Fayetteville, North Carolina

RISK MANAGEMENT

Sharon L. Groves, RN, MSA, ARM, FASHRM, CPHRM, AVP Clinical Risk

 Manager, General Electric Employers Reinsurance Corporation, The 

 Medical Protective Company, Columbus, Ohio

Faye W. Robbins, ARM, CPHRM, Risk Management, Roper Saint Francis

 Healthcare System, Charleston, South Carolina

OTHER PROFESSIONS

Christine Candio, RN, FACHE, Chief Executive Officer, Inova Alexandria 	 	

Hospital, Senior Vice President, Inova Health System, Alexandria, Virginia

Stephen J. Hall, President and Chief Executive Officer, Best Security Indus-	 	

tries, Delray Beach, Florida

	 John Kittle, Mead Johnson Nutrition, Atlanta, Georgia

NATIONAL CENTER FOR MISSING & EXPLOITED CHILDREN

	 John B. Rabun, Jr., ACSW, Executive Vice President and Chief Operating Officer

Cathy Nahirny, Administrative Manager, Jimmy Ryce Law Enforcement

 Training Center

Marsha Gilmer-Tullis, Director, Family Advocacy Division

Nancy McBride, National Safety Director

Theresa A. Delaney, Director of Publications

Christina Miles, Publications Specialist

Erin K. Fitzgerald, Publications Specialist

vi - For Healthcare Professionals
For Healthcare Professionals - vii

A Message to the Reader

The Joint Commission (TJC), an accrediting agency, is a private, not-for-profit

organization dedicated to improving the quality and safety of medical care provided 

to the public. It is an agency that sets the principal standards and evaluations for a 

variety of healthcare organizations. Infant/pediatric security is an area of concern to

TJC as a high-risk security area often referred to as “security-sensitive area.” Such

areas require a specific access-control plan, initial and periodic security-related

training for staff members working in those designated areas, and a critical-incidentresponse plan. It is common for TJC surveyors to ask in-depth questions regarding 

the implementation of infant/pediatric security plans.

Infant/pediatric abductions or discharge to the wrong family are reviewable

sentinel events under the sentinel-event standards of TJC. A Sentinel Event Alert 

relative to infant abductions was issued by TJC on April 9, 1999, and is available on 

TJC’s website at www.jointcommission.org. In addition the TJC 2002 publication

titled Security Issues For Today’s Health Care Organizations and the 2009 TJC Comprehensive Accreditation Manual for Hospitals: The Official Handbook should be consulted 

as important reference information. The primary TJC security requirements relative to infant security are found in the Environment of Care Section EC.02.01.01, 

which in 2009 combined the previously separated areas of security and safety. TJC 

publicationsmay be obtainedthroughJoint CommissionResources at www.jcrinc.com

or 877-223-6866.

The International Association for Healthcare Security and Safety (IAHSS) publishes Healthcare Security: Basic Industry Guidelines. Guideline 09.02 addresses infant/

pediatric security and is available in booklet form and on the Web at www.iahss.org 

or 1-888-353-0990.

The National Quality Forum (NQF) in 2002 published 28 serious reportable 

events. This was an effort of the NQF to address healthcare safety. The events are

easily identifiable and measurable and are of a nature such that a risk of occurrence

is influenced by policies and procedures of the healthcare facility. One of these 28

serious reportable events is abduction of a patient of any age. Centers for Medicare 

and Medicaid have linked payment to some of these events. Patient Safety — 

Obstetrical “never events” have listed infant abduction as one of these events.

The “guidelines” presented in this document are intended to provide, in part, 

security strategies and protocols that support and enhance TJC and IAHSS security 

guidelines. NCMEC encourages facilities that are not accredited by TJC to follow 

the intent of TJC requirements and IAHSS guidelines.

The information and practices described in these guidelines have been provided 

for informational purposes only and are not intended to be relied upon as legal 

advice. This publication may contain information that is time-sensitive and subject

to change. Obtain legal advice from qualified healthcare counsel before acting in

any specific situation. This information is not intended to be exhaustive about the

subjects addressed. There is no guarantee any benefit will accrue to entities that

adhere to these points. Any resources or websites are offered as reference points

only and without endorsement to content, accuracy, or currency.
Caution The focus of this publication is defined by the criteria of age of the victim and 

motivation for the abduction. The cases discussed involve the abduction of infants, 

birth through 6 months, for “nontraditional” motives. The age criterion is fairly 

straightforward and obvious. It is also the reason for use of the common descriptive term “infant abduction” throughout this book. It should be noted an infant 

is “missing” and presumed “abducted” until proven otherwise. The motivation 

criterion in these types of abductions is more complicated, more uncertain, and 

the reason for use of the term “nontraditional abduction.” The term “nontraditional” refers to child abductions not motivated by more commonly seen reasons 

such as sexual gratification, profit, ransom, revenge, and power. This publication 

focuses on cases apparently motivated by the offender’s need to have a child to 

fill a perceived void in her life. Because motivation often is not discernable with 

certainty, readers must use caution when applying the findings set forth in this 

publication. It cannot be assumed the abduction of every infant is motivated by 

these nontraditional reasons and therefore fits the dynamics set forth. Individuals 

with other motivations and characteristics may also abduct infants. In addition 

offenders with the discussed motivations and characteristics may abduct toddlers and even older children. Regardless of the setting, circumstances, or 

perceived offender motivation, ALL professional and law-enforcement 

efforts must have only one common primary goal of THE SAFE RETURN 

OF THE INFANT.

viii - For Healthcare Professionals
For Healthcare Professionals - ix

Photo composite

of Kamiyah Mobley

who was abducted from 

her mother’s hospital 

room in July 1998.

Nonfamily Abduction

The images shown are all composites. Kamiyah was abducted from her mother’s room at University Medical Center in Jacksonville, 

Florida, at 3:00 p.m., on July 10, 1998. The suspect, a black female, approx. 25-35 yoa, 130-160 lbs, was dressed in a nurse’s blue floral 

smock and green scrub pants. She may wear wigs and glasses. Kamiyah has Mongolian spots on her buttocks which tend to fade in 

6-8 months and an umbilical hernia. No infant metabolic screening has been performed. Birth mother has tested positive for sickle cell 

anemia and strep type B.

ANYONE HAVING INFORMATION SHOULD CONTACT

NATIONAL CENTER FOR MISSING & EXPLOITED CHILDREN

1-800-843-5678 (1-800-THE-LOST) or

Jacksonville Sheriff’s Office (Florida) - 1-904-630-0500

FBI (Jacksonville, Florida) - 1-904-721-1211 Or Your Local FBI

DOB: Jul 10, 1998

Missing: Jul 10, 1998

Age Now: 10

Sex: Female

Race: Black

Hair: Black

Eyes: Brown

Height: 1’9” (53 cm)

Weight: 8 lbs (4 kg)

Missing From:

JACKSONVILLE

Florida

United States

Suspect

DOB: Jan 1, 1968

Sex: Female

Race: Black

Hair: Black

Eyes: Brown

Height: 5’5” (165 cm)

Weight: 145 lbs (66 kg)

KAMIYAH MOBLEY SUSPECT COMPOSITE

Composite No Wig No Glasses

1. The Problem

While not a crime of epidemic proportions, the abduction, by nonfamily members, 

of infants, birth through 6 months, from healthcare facilities has clearly become a 

subject of concern for parents, maternal-child-care nurses, healthcare security and

risk-management administrators, law-enforcement officials, and the National Center

for Missing & Exploited Children (NCMEC). With the goal of preventing crimes

that are committed against children, NCMEC — in cooperation with the Federal

Bureau of Investigation (FBI), International Association for Healthcare Security and 

Safety (IAHSS), and Boston College School of Nursing — has studied infant abductions from birthing/healthcare facilities, homes, and other sites and considers them

preventable in large part by “hardening the target” as described in this book.

Based on a study of cases from 1983 through 2008, the best estimate for the 

nationwide incidence of infant abductions, by nonfamily members, ranges between 

0 and 10 per year. Because a number of cases may not be reported to NCMEC or 

other organizations, this estimate may be conservative. As a point of comparison, in 

2007 there were more than 4 million births in the United States,1

 and there are nearly 

3,000 birthing facilities.2

 In 124 of the cases studied the infants were abducted from 

the premises of healthcare facilities, and 99 were infant abductions from the home 

that followed most of the same patterns as the abductions from healthcare facilities

but with the addition of violence committed against the mother or other present

caregiver. Thirty-three (33) additional infants were abducted from other places such 

as malls, offices, and parking lots. The bed size of a facility, urban or rural, does not

seem to be a factor as to whether or not they will experience an abduction. Of all

the infants abducted from healthcare facilities, 95 percent were located and safely 

returned, usually within a few days to two weeks.

Because anecdotal evidence would suggest there may be numerous abduction attempts 

at birthing facilities each year, information regarding attempted abductions should

be reported to NCMEC at 1-800-THE-LOST® (1-800-843-5678). When submitting

information, the name of the healthcare facility may be excluded, but NCMEC

would appreciate knowing the city in which the incident occurred and bed size of 

the healthcare facility reporting the incident. NCMEC wishes to collect this information in order to identify any possible changes in the profile or emerging trends

in the abduction of infants.

For Healthcare Professionals - 1

1

According to “Births, Marriages, Divorces, and Deaths: Provisional Data for 2007” in National Vital Statistic Reports, Vol. 56, No. 21, July 14, 2008, page 

1, there were 4,315,000 live births in 2007, the most recent year of available data.

2

According to the American Hospital Association 2,800 hospitals in the United States reported having obstetrics inpatient care units in 2007 (AHA 

Hospital Statistics: The Comprehensive Reference Source for Analysis and Comparison of Hospital Trends, 2009 Edition, page 156). On November 14, 2008, a 

representative of the National Association of Childbearing Centers stated there are approximately 190 free-standing birthing centers in the United States.
2 - For Healthcare Professionals

TOTAL - Abductions of Infants from 1983-2008: 256

TOTAL - Still Missing: 12

1983-2008 Case Status

HEALTHCARE FACILITIES 124 Located = 118

 Still Missing = 6

Mother’s Room 71 (57%)

Nursery 17 (14%)

Pediatric Units 17 (14%)

“On premises”

(outside building

but still on grounds) 19 (15%)

With Violence to

Mother “On Premises” 9 (7%)

HOMES 99 Located = 95

 Still Missing = 4

With Violence

to Mother 29 (29%)

“OTHER PLACES” 33 Located = 31

 Still Missing = 2

With Violence

to Mother 8 (24%)

*To date there has been no use of violence (or attempts) against the mothers within 

healthcare facilities; however, there have been several cases where assault and battery 

have occurred against nursing staff members during abduction attempts and abductions. 

In addition there is clear evidence of increasing violence by abductors when the abductions 

move outside of the healthcare setting.
For Healthcare Professionals - 3

The typical abduction from a healthcare facility involves an “unknown” abductor 

impersonating a nurse, healthcare employee, volunteer, or relative in order to gain 

access to an infant. The obstetrics unit is an open and inviting one where patients’

decreased length of stay, from one to three days, gives them less time to know staff

members. In addition it can be filled with medical and nursing staff members, visitors, students, volunteers, and participants in parenting and newborn-care classes. 

The number of new and changing faces on the unit is high, thus making the unit an 

area where a “stranger” is unlikely to be noticed. Because there is generally easier 

access to a mother’s room than to the newborn nursery and a newborn infant spends

increasingly more time with his or her mother rather than in the traditional nursery 

setting, most abductors “con” the infant directly from the mother’s arms.

Total Infant Abductions in the United States

from 1983 - 2008

N = 256

Source: National Center for MIssing & Exploited Children

Environmental Systems Research Institute (ESRI), Inc. Redlands, CA

Mapping software donated to NCMEC by ESRI

January 8, 2009

AK

AL

3

GA

9

FL

19

SC

5

MS

3

AR

3

AZ

4

CA

33

CO

6

IL

14

IN

2

IA

1

KS

3

KY

3

ME

1

MI

6

MN

1

MO

7

MT

1

NV

1

NM

4

NC

4

OH

10

OK

4

OR

2

PA

8

SD

1

TN

5

TX

33

UT

2 VA

8

WA

4

WV

1

WI

2

NY

10

CT - 2

DC - 6

DE - 1

MA - 2

MD - 10

NH - 1

NJ - 6

RI - 1

PR

4
4 - For Healthcare Professionals
For Healthcare Professionals - 5

2. The Offender and Modes of Operation

The offender

n Is almost always a female

n Is frequently overweight

n Ranges in age from 12 to 53 but, in general, is in her early 20s; and usually has 

no prior criminal record

If the offender has a criminal record, however, it is often for fraudulent activity

such as

n	 Shoplifting

n Passing bad checks

n Forgery

Many of these women are gainfully employed. While she appears “normal,” 

the woman is most likely

n Compulsive

n	 Suffers from low self-esteem

n	 Often fakes one or more pregnancies

n Relies on manipulation and lying as coping mechanisms in her interpersonal relationships

The infant may be used in an attempt to maintain/save a relationship with her

husband, boyfriend, or companion (hereinafterreferred to as the significant other).

Sometimes she wishes either to “replace” an infant she has lost or experience a

“vicarious birthing” of an infant she is for some reason unable to conceive or carry 

to term. On occasion an abductor may be involved in a fertility program at/near

the facility from which she attempts to abduct an infant. Of the 248 cases where the

abductor’s race is known, 105 are Black, 94 are Caucasian, 48 are Hispanic, and 1

is Asian. The race/skin color of the abductor almost always matches the infant’s or

reflects that of the abductor’s significant other.

Of the 124 infants who were abducted from healthcare facilities, 65 percent 

were 7 days old or younger. As a point of comparison, of the 99 infants who were 

abducted from homes, 21 percent were 7 days old or younger. Of the 33 infants 

who were abducted from other locations, 12 percent were 7 days old or younger. 

The abducted infant is perceived by the abductor as “her newborn baby.” A strong 

gender preference, in the abduction of these infants, is not revealed in the data.

Although the crime may be precipitated by impulse and opportunity, the 

abductor has usually laid careful plans for finding another person’s infant to take

and call her own. In addition, prior to the abduction, the offender will often exhibit

“nesting” behavior by “announcing her pregnancy” and purchasing items for an 

infant in the same way an expectant mother prepares for the birth of her baby. The

positive attention she receives from family and friends “validates” her actions.
Unfortunately this “nesting” activity feeds the need for the woman to “produce” a 

baby at the expected time of arrival.

Many of these abductors have a significant other at the time of the abduction, and a high percentage of them have already given birth to at least one child. 

Typically, of the women married/cohabitating/involved in a relationship at the time

they abduct an infant, their significant other — sometimes a considerably older or

younger person — is not known to be involved in the planning or execution of the

abduction, but may be an unwitting partner to the crime. The significant other is

often very gullible in wanting to believe his wife/girlfriend/companion indeed gave

birth to or adopted the infant now in her possession and may vehemently defend 

against law enforcement’s attempts to retrieve the baby.

The vast majority of these women take on the “role” of a nurse or other healthcare staff person, such as a lab technician, health-department employee, social

worker, or photographer, and represent themselves as such to the victim mother 

and anyone else in the room with the mother. Once the abductor assumes this role, 

she asks to take the baby for tests, to be weighed, to be photographed, or for other 

logical purposes in the healthcare setting. Obviously, arriving at the decision to ask

the mother if she can take the infant for a “test” or “photograph” takes forethought 

on the part of the abductor.

The pretense of being someone else is most often seen in abductors who use

interpersonal coping skills including manipulation, conning, lying, and ruses. 

These women demonstrate a capability to provide “good” care to the baby once 

the abduction occurs. The infants who have been recovered seem to have suffered

no ill effects and were found in good physical health. The offenders, in fact, consider the babies to be “their own.” There is no indication these are “copycat” 

crimes, and most offenders can be found in the same general community where

the abduction occurred.

These crimes are not always committed by the stereotype of the “stranger.” In

most of these cases the offenders made themselves known and achieved some

degree of familiarity with healthcare personnel, procedures, and the victim parents. 

The abductor, a person who is compulsively driven to obtain an infant, often visits

the nursery and maternity unit for several days before the abduction, repeatedly asking detailed questions about healthcare-facility procedures and becoming familiar 

with the layout of the maternity unit. While the majority of the abductors visit the

maternity unit in the days prior to the abduction, and pose as a nurse, some abductors are known to have been former employees, former patients, or have a friend or 

relative who was a patient at the facility where the crime is committed. Moreover,

the women who impersonate nurses or other healthcare personnel usually wear 

uniforms or other healthcare-worker type of attire. They have also impersonated

home-health nurses, staffers with financial-assistance programs, and other professionals who may normally work in a healthcare facility. They often visit more than

one healthcare facility in the community to assess security measures and explore

infant populations, somewhat like “window shopping.”

6 - For Healthcare Professionals
For Healthcare Professionals - 7

The abductor may also follow the motherto the home setting.As of the publication of this book in January 2009, there has been no use of violence against mothers 

within healthcare facilities; however, there have been several cases where assault 

and battery have occurred against nursing staff members during abduction attempts

and abductions. In addition 29 percent of the abductions from homes involved some 

type of violent act committed against the mother including homicide. Clearly the

location of abduction in the last few years seems to be changing from the healthcare 

to home setting as evidenced by the fact there was violence committed against the

parent in a total 46 cases from 1983 to 2008, but, of those cases, 29 occurred from 

1996 through 2008.

The abductor may not target a specific infant for abduction. When an 

opportunity arises, she may quickly “snatch” an available victim, often be visible

in the hallway for as little as four seconds with the infant in her arms, and escape 

via a fire-exit stairwell. It is not uncommon for the abductor to focus on mothers’

rooms located closest to a stairwell exit to allow for immediate flight and minimize

contact with others they might encounter in an elevator or public stairwells. Since 

the abductoris compelled to show off her new infant to others, use of the broadcast

media to publicize the abduction is critical in encouraging people to report situations 

they find peculiar. Most often infants are recovered as a direct result of the leads

generated by media coverage of the abduction when the abductor is not portrayed 

in the media as a “hardened criminal.”

For the first time since 1983, the incidence of nonfamily infant abductions from 

healthcare facilities decreased to ZERO in 1999. This reduction seems directly attributable to 17 years of proactive-education programs combined with “hardening 

the target” through the procedural and security measures discussed herein. The 

primary seminar, Safeguard Their Tomorrows, has been sponsored by AWHONN 

(the Association of Women’s Health, Obstetric, and Neonatal Nurses—formerly

NAACOG); the National Association of Neonatal Nurses (NANN); and NCMEC, 

as underwritten, in part, by Mead Johnson Nutrition in association with IAHSS.

Education has greatly increased the awareness of nursing and security staffs in

healthcare facilities nationwide. In the last 21 years the author has provided direct 

educational training to more than 64,000 healthcare professionals and informal 

on-site, maternal-child-care-unit assessments for more than 1,000 healthcare facilities 

nationwide, in Canada, and in the United Kingdom. In addition NCMEC and Mead 

Johnson Nutrition have published more than 527,000 copies of this award-winning 

publication For Healthcare Professionals: Guidelines on Prevention of and Response to 

Infant Abductions (formerly titled For Healthcare Professionals: Guidelines on Preventing 

Infant Abductions and For Hospital Professionals: Guidelines on preventing abduction of 

infants from the hospital).
8 - For Healthcare Professionals
For Healthcare Professionals - 9

3. Guidelines for Healthcare Professionals

The guidelines highlighted in bold print are considered ESSENTIAL

for the prevention and documentation every facility should

strive to meet. All other guidelines listed are highly recommended.

3-1 General

The intent of these guidelines is to encourage healthcare facilities to develop 

security standards, to better protect infants, which are reasonable, appropriate, and

defensible. Safeguarding newborn infants requires

 A comprehensive program of healthcare policy, procedures, and processes

 Education of and teamwork by nursing personnel, parents, physicians, security, 

and risk-management personnel

 Coordination of various elements of physical and electronic security if applicable

Collectively, all three actions serve to “harden the target” of potential abductors. 

Without question,the firsttwo elements can and should be immediately implemented

at all healthcare facilities.

A multidisciplinary approach to the development of specific healthcare policies and critical-incident-response plans, should an abduction occur, is needed 

to effectively combat this infrequent but highly visible crime. Nurse managers/

supervisors may be well suited to take a lead role in this approach because of the 

holistic philosophy of nursing, the large amount of nursing time spent with parents 

and infants, the educational component of nursing care, and the ability of nurse 

managers/supervisors to incorporate teaching infant safety to parents and other

staff members. Additionally, obstetric, nursery, and pediatric nurses, given the

nature of maternal-child care, have close working relationships that would facilitate 

implementation of effective policies and process-improvement measures. In the

healthcare facility, nurses are “surrogate parents” and the front line of defense in 

preventing abductions and documenting any incidents that occur.

Electronic security measures are simply modern tools used to “back up” a 

healthcare facility’s policies and procedures and nursing practices. These devices

are designed to further discourage or deter potential abductors and augment the 

overall protection process. They may also serve as a physical basis for enhancing 

the ability of nursing, security, and risk-management personnel to work as a team. 

There are several technologies available for this purpose including video-surveillance systems (i.e., closed-circuit television [CCTV]) backed up with recording, 

access control, and infant-bracelet-tag alarms. Each one, used singly or in some 

combination, provides several potential benefits. First these systems are reliable

when properly designed, installed, tested, serviced, and maintained. These systems 

are constantly vigilant and unaffected by distractions, rest/lunch breaks, and shift
changes; however, these systems are not infallible and need to be tested. As such 

regular, scheduled testing of each system’s operational elements, in accordance

with the manufacturer’s specifications, is required as is a post-alarm assessment

in order to determine the cause of the alarm. Second, and more importantly, such 

systems serve to document and help deter, not simply prevent, an abduction. Digital 

recording, coupled with access control, serves to document a potential abduction 

as it unfolds. They may also help in resolving and documenting “false alarms” of 

systems, varying according to manufacturer, for supervisory and/or investigative

follow-up. Additionally, CCTV cameras and alarm panels, coupled with security 

signage, serve as a visual deterrent to the potential abductor. If properly used by 

facilities, these precautions clearly add to the potential of deterring an abduction; 

identifying and locating the abductor more quickly when an abduction does 

occur; and, most importantly, aiding in recovering an abducted infant. Regardless 

of the safety controls selected and implemented, parents and staff members must

always understand the security and surveillance systems described herein are not 

a substitute for continuous and personal vigilance toward infant security. These 

healthcare-organization policies and measures in no way diminish the empowerment of the parents in their responsibilities to their newborn infant, but together 

they can better “safeguard their tomorrows.”

Each facility’s chief executive officer, with the appropriate management-staff

members, should regularly review specific protocols and critical-incident-response

plans to see if all issues concerning security measures are addressed. Such a review 

should both help prevent abductions and document any that do occur. It should 

also allow a facility to review the prescribed measures to be taken in case an infant 

abduction occurs at their facility and help them document the fact that reasonable 

and appropriate measures are in place and/oridentify areas needing to be improved.

The guidelines enumerated in this chapter will aid facilities in this process. See

Chapter “7. Self-Assessment for Healthcare Facilities” beginning on page 59 that is 

a summary of these guidelines. To create a justifiable and defensible posture, each

facility should use a multidisciplinary team to conduct a self-assessment with this 

tool and note how they meet these guidelines or document what is not applicable to 

their facility and why. Once this assessment step is completed facilities should use 

the outline created to review and modify their policies and procedures as needed 

based on the format of these national guidelines.

Be alert to unusual behavior. Healthcare security, nursing, and risk-management 

administrators should remind all personnel that the protection of infants is a proactive responsibility for everyone in the facility, not just for security. One of the most

effective means of thwarting, and later identifying, a potential abductor is to use

phrases like, “May I help you?” and “Who are you here to visit?” emphasizing the 

need to obtain the name of the mother the person wishes to visit. When asking these 

questions, make eye contact, carefully observe the person’s behavior, note a physical

description, and follow-up as is appropriate for the situation. All healthcare-facility

10 - For Healthcare Professionals
personnel should be alert to any unusual behavior they encounter from individuals such as

n	 Repeated visiting or requests “just to see” or “hold” the infants.

n Close questioning about healthcare-facility procedures, security devices, and

layout of the floor such as, “When is feeding time?” “When are the babies taken

to the mothers?” “Where are the emergency exits?” “Where do the stairwells

lead?” “How late are visitors allowed on the floor?” “Do babies stay with their

mothers at all times?”

n	 Taking uniforms or other means of identification within that facility.

n	 Physically carrying an infant in the facility’s corridor instead of using the bassinet to transport the infant, or leaving the facility with an infant while on foot 

rather than in a wheelchair.

n	 Carrying large packages off the maternity unit (e.g., gym bags, suitcases, backpacks), particularly if the person carrying the bag is “cradling” or “talking” to it.

Be aware that a disturbance may occur in another area of the healthcare facility 

creating a diversion to facilitate an infant abduction (e.g., fire in a closet near the

nursery or loud, threatening argument in the waiting area). Healthcare facilities 

need to be mindful of the fact that infants can stay in or need to be taken to many 

areas within the facility. Thus vigilance for infant safety must be maintained in all 

areas of the facility when infants are present.

General Guidelines

3-1-1 Persons exhibiting the behaviors described above should be immediately 

asked why they are in that area of the facility. Immediately report the person’s behavior and response to the nurse manager/supervisor, security, and 

administration. The person needs to be positively identified, kept under 

close observation, and interviewed by the nursing manager/supervisor 

and security. Remember, caution needs to be exercised when interacting

with people who exhibit these behaviors.

3-1-2 Report and interview records on the incident should be preserved in 

accordance with the organization’s internal procedures. (Many suggest 

records should be kept from a minimum of seven years up to the child 

reaching adulthood.)

3-1-3 Each facility should designate a staff person in their critical-incident 

response plan who will have the responsibility to alert other birthing 

facilities in the area when there is an attempted abduction or someone is 

identified whom demonstrates the behaviors described above, but who 

has not yet made an attempt to abduct an infant.

For Healthcare Professionals - 11
Each facility should develop a concise, uniform reporting form to facilitate 

the timely recording and dissemination of this information to see that due 

diligence is used in sharing knowledge about a potential abduction or 

abductor. Care should be taken that this alert does not provide material for 

a libel or slander suit against the facility by the identified person. See the 

“Sample Notification Form” on page 35 adapted from a form designed by

Jeff Karpovich when affiliated with the HCA Raleigh Community Hospital

and reprinted with his permission.

3-1-4 Notify authorities at the local law-enforcement agency, then notify

NCMEC at 1-800-THE-LOST® (1-800-843-5678) of all attempted/thwarted 

abductions. Information reported to NCMEC may be submitted anonymously to protect the confidentiality of the facility and is most helpful in

assisting NCMEC in learning more about what strategies are most effective

in thwarting abduction attempts.

3-2 Proactive Measures

The guidelines highlighted in bold print are considered ESSENTIAL

for the prevention and documentation every facility should

strive to meet. All other guidelines listed are highly recommended.

Proactive-Prevention Guidelines

3-2-1 As part of contingency planning, the backbone of prevention, every healthcare facility must develop, test, and critique a written proactive-prevention 

plan for infant abductions that includes all of the elements listed in this 

section. In addition measures must be taken to inform new or rotating 

(temporary) employees of these procedures as they join the staff. This

plan needs to be tested, documented, and critiqued at least annually.

3-2-2 Immediately after the birth of the infant and before the mother and infant 

are separated, attach identically numbered ID bands to both the infant (2 

bands) and mother (1 band) and 1 band to the father or mother’s significant 

other when appropriate. Inform parents of the reason or need for the bands.

	 If the fourth band is not used by the father/mother’s significant other, that

fact must be documented. This band may be stapled to the chart or cut and 

placed in the “sharps box.” For information about the importance of bands

in regard to transporting infants see 3-2-6(a) on page 16.

An infant’s band needs to be verified with the mother when taking the 

infant for care as well as upon delivery of the infant to the mother after 

care has been rendered. The caregiver must examine and verify both the 

baby and the mother’s (or significant other’s) identification bands and 

have the mother (or significant other) do the same.

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If an infant band is removed for medical treatment or comes off for any

reason, immediately reband the infant after identifying the infant, using

objective means such as footprint comparisons or blood testing, and change

all bands, mother’s, father’s/significant other’s, and infant’s, so once again

the bands all have the same number. If the band is cut or entirely removed, 

parents should be present at the removal and replacement.

No matter what form of attachment bands (or clamps) are used with the electronic 

tagging of infants, healthcare facilities should be very careful to assure there is 

never any delay in activation of the alarm function upon separation and should 

perform frequent, ongoing testing in support of that guideline. Staff members 

should be trained to immediately respond so there is no delay between detection 

of the alarm condition and generation of the alarm notification. Staff members 

should never consider an alarm to be a “false alarm.”

Case

Example After the birth of her daughter, and while still a patient, a new mother was 

approached by a woman claiming to be a social worker from another hospital 

who was there to conduct a survey and provide assistance to needy families.

 The “social worker” spent the day at the hospital, entering and exiting this 

patient’s room several times. At one point she brought in and left a suitcase. 

During the day the victim mother’s family was also in the room with her as the 

woman came and went. They too believed this woman was a social worker and 

observed what appeared to be an empty ID holder partially hidden by her suit 

jacket. While the victim mother and her family believed the “social worker” was 

a staff member of a nearby healthcare facility, staff members of that healthcare 

facility were under the impression the woman was a member of this infant’s family.

 At approximately 9:00 p.m., after the mother’s family had left, the “social 

worker” insisted the victim mother take a shower and get ready for bed. Around 

9:20 p.m., the mother entered the bathroom and exited about 5 minutes later to 

discover her infant, the woman, and the suitcase were gone. The mother 

immediately contacted the nurses’ station, and security and law enforcement were 

called. The local law-enforcement agency issued a be-on-the-lookout (BOLO) 

bulletin for the suspect.

 A few hours later a uniformed officer observed the suspect at a fast-food restaurant about four blocks from the healthcare facility. The officer made eye contact 

with the suspect, and the suspect immediately left the restaurant. Her physical 

description and behavior reminded the officer of the BOLO, and he followed her 

from the restaurant. The woman and the infant were taken into custody after the 

suspect was unable to satisfactorily answer the officer’s questions.

 Key Factors Helping to Recover the Infant

 Key factors that helped in recovering this infant included the

  Victim mother did not delay in notifying staff members her baby was missing
 Healthcare facility did not delay in contacting law enforcement, and law 

enforcement immediately issued a BOLO

 Arresting officer heard the BOLO and followed through when observing the 

suspect and her behavior at the restaurant

Teaching Points

Facilities need to conduct frequent, ongoing testing of infant-tagging security 

systems to ensure they are properly functioning. See 3-2-2 beginning on page 12 

for additional information regarding these points.

Facilities also need to consider protecting nursery units in the same way behavioral 

units are protected, when possible with electronic card-in and card-out readers 

for authorized staff members and ask-in and ask-out for visitors to help eliminate 

confusion regarding who is a visitor and who is a staff member. See 3-2-11 on page 

18 and 3-3-3 on page 21 for additional information regarding these points.

Facilities also need to take every opportunity to educate parents about the procedures used by the facility to identify staff members including ID badges worn by 

various personnel within and affiliated with the facility. See 3-2-4 and 3-2-5 beginning on page 15 for additional information regarding the use of ID badges.

3-2-3 Prior to the removal of a newborn from the birthing room or within a 

maximum of two hours of the birth

a. Footprint (with emphasis on the ball and heel of the foot) the infant 

making sure the print is clear. Repeat if necessary.

b. Take a color photograph or color video/digital image of the infant.

c. Perform a full, physical assessment of the infant, and record, in the 

medical chart, the assessment along with a description of the infant.

d. Store a sample of the infant’s cord blood and any other blood specimens until at least the day after the infant’s discharge.

e. Place electronic security tags, if such a system is being used.

The footprints, photograph or video/digital image, physical assessment, 

and documentation of the placement of the ID bands, including their 

number, must be noted in the infant’s medical chart.

Take footprints of each infant at birth/admissions/readmissions. Take a

complete impression of the infant’s foot using light pressure to capture ridge

detail on the ball and heel of the foot.

	 Occasionally footprints of the newborn are unreadable or difficult to obtain,

but footprints are an excellent form of identification if an abducted infant is

recovered. Thus healthcare facilities should take good, readable footprints 

of each infant. Consult your local FBI office or law-enforcement agency for

appropriate techniques, paper stock, various products, and methods to capture prints. For further information about footprint techniques see Michael 

E. Stapleton’s 1994 article about footprinting listed in the “Bibliography” on

page 80.

14 - For Healthcare Professionals
No matter which footprinting method is used — ink or “inkless” — care 

should always be taken to obtain clear, readable footprints with an emphasis 

on the ball and heel of the infant’s foot.

Like footprints, cord blood collected at the time of delivery is an excellent

form of identification. Deoxyribonucleic acid (DNA) testing foridentification

purposes, “DNA Fingerprinting,” is considered the best current method of 

biological identification. There are two types of DNAtests because there are

two types of DNA in human cells. They are mitochondrial DNA (mtDNA) 

and nuclear DNA. Nuclear DNA tests are based on short tandem repeat 

(STR) DNAsequences and have been used extensively in criminal cases and

situations like identifying samples from the World Trade Center attack in

2001. While mtDNAanalysis is strong circumstantial evidence foridentification, using STRs as a match between a known infant reference sample and a 

“questioned” sample would be taken as conclusive, positive identification.

Nuclear DNA testing has become routine. In fact, in an emergency situation, 

a definitive identification made from DNAcan now be accomplished in less

than 24 hours rather than the weeks it used to take, depending on specific

laboratory requirements. If a healthcare facility chooses to use DNA rather 

than footprints, it should have a signed contract with a laboratory specifying 24 hour coverage, 365 days a year with a 4 to 6 hour turn around for 

infant ID tests. Although cord blood provides the best sample, even if cord 

blood is not available, a simple swab from the inside of the infant’s cheek

will generate enough material to perform a DNA test. At a minimum the 

healthcare facility needs to store the sample of cord blood, dried onto a piece 

of sterile filter paper, or the dried mouth swab until the day after the infant

is discharged from the facility or longer as a facility’s policy dictates.

Take clear, high-quality, color photographs, or digital images, of all infants 

at birth and up to 6 months of age upon admissions including a close-up 

of the face, taken “straight on,” and retain it at least until the infant is discharged. Inform parents an admissions photograph of their infant will be 

taken for identification purposes and/or obtain permission from them to

take the photograph.

When completing the physical assessment of the infant, identify and document any marks or abnormalities such as skin tags, moles, and/or birthmarks.

While the footprint, photograph, and assessment must be placed in the 

infant’s medical records, parents may wish to keep a copy of this information for their own records.

3-2-4 Require all healthcare-facility personnel to wear, above the waist and 

“face-side” out, up-to-date, conspicuous, color-photo ID badges. The 

person’s name and title need to be easily identifiable, and the person’s 

For Healthcare Professionals - 15
photograph needs to be large enough so that he or she is recognizable. 

Update the photograph as the person’s appearance changes. These badges 

need to be returned to Human Resources or the issuing department 

immediately upon termination of employment. All missing badges must 

be immediately reported and the appropriate security response enacted. 

Consider placing the staff member’s photograph and identifying information on both sides of the badge to help ensure the photograph and all 

identifying information is fully readable no matter which side of the badge

is facing the public. And, as recommended by the International Association 

for Healthcare Security and Safety in their Healthcare Security: Basic Industry 

Guidelines regarding access control and identification systems, healthcare

facilities should “expire” and reissue previously issued badges at a minimum

of five years from the date of issue (07.01(e)).

3-2-5 Personnel who are permitted to transport infants from the mother’s room 

or nursery, including physicians, should wear a form of unique identification used only by them and known to the parents (e.g., a distinctive and 

prominent color or marking to designate personnel authorized to transport 

infants). IDs should be worn above the waist, “face-side” out, on attire that 

will not be removed or hidden in any way. Paraphernalia should not be worn 

on name badges (i.e., pins, stickers, and advertisements) that hide name, 

face, or position. ID systems should include provisions for all personnel, 

who are permitted to transport infants from the mother’s room or nursery 

including students, “transporters,” and temporary staff members, such as 

the issuance of unique temporary badges that are controlled and assigned 

each shift (e.g., strict control should be similar to narcotics control). This 

unique form of identification should be periodically changed.

Facilities need to address issues of assisting hearing, visually, physically, and 

mentally challenged patients with their special needs in this identification

process. This should also address any language barriers that may exist.

3-2-6 Concerning infant transportation within the healthcare facility

a. Limit infant transportation to an authorized staff member wearing the 

authorized infant-transportation ID badge.

b. Ensure the mother or father/significant other with an identical ID band 

for that infant are the only others allowed to transport that infant, and 

educate the mother and father/significant other about the importance 

of this precaution.

c. Prohibit leaving an infant without direct, line-of-sight supervision.

d. Require infants to be taken to mothers one at a time. Prohibit “grouping” infants while transporting them to the mother’s room, nursery, 

or any other location.

e. Prohibit “arm carrying” infants, and require all transports to be via 

a bassinet.

16 - For Healthcare Professionals
Require family members transporting the infant outside the mother’s room, 

including the mother, father, or significant other, to wear an ID wristband. 

All wristbands should be coded alike numerically and readily recognizable.

3-2-7 Distribute the guidelines for parents in preventing infant abductions, 

listed in “What Parents Need to Know” beginning on page 51, to parents 

during prenatal visits to their OBGYN, in childbirth classes, on preadmission tours, upon admission, at postpartum instruction, and upon 

discharge. Upon admission consider having the patient sign a document 

noting receipt of these guidelines with the patient retaining the guidelines 

and a copy of this signed document. Also consider permanently posting this 

information on patients’ bathroom doors and/or in a prominent location

within the mother’s room, in the form of a poster, during their stay. This 

same information needs to be distributed to all new/current staff members and physicians and their staff members who work with newborns, 

infants, and child patients.

3-2-8 Provide staff members, at all levels, instruction, at least annually, about 

protecting infants from abduction including, but not limited to, information about the offender profile and unusual behavior, prevention procedures, 

their responsibilities, and critical-incident-response plan.

Consider the use of the DVD titled Safeguard Their Tomorrows provided by 

Mead Johnson Nutrition as an excellent educationalresource in this instructional process. It can be obtained free-of-charge by contacting your local 

Mead Johnson Nutrition medical sales representative.

3-2-9 Always place infants in direct, line-of-sight supervision either by a responsible staff member, the mother, or other family member/close friend so 

designated by the mother, and address the procedure to be followed when 

the infant is with the mother and she needs to go to sleep/the bathroom 

and/or is sedated. If the mother is asleep when the infant is returned to the 

room, staff members should be careful to fully awaken her before leaving

the room. In rooming-in situations, place the bassinet so the mother’s bed

is between the exit door(s) to the room and the bassinet.

3-2-10 Do not post the mother’s or infant’s full name where it will be visible to 

visitors. If necessary, use surnames only. Do not publish the mother’s or 

infant’s full name on bassinet cards, rooms, status or white boards. Do not 

leave charts, patient index cards, or any other medical information visible 

to anyone other than medical personnel. Be aware that identifying information in the bassinet such as ID cards with the infant’s photograph and 

the family’s name, address, and/or telephone number may put the infant 

and family at risk after discharge. Keep this information confidential and 

out of sight. Do not provide patient information via the telephone.

For Healthcare Professionals - 17
3-2-11 Establish an access-control policy for the nursing unit, nursery, maternity, 

neonatal-intensive care, and pediatrics to maximize safety. At the front 

lobby or entrance to the maternity unit, instruct healthcare-facility personnel to ask visitors which mother they are visiting. If no name is known or 

given, decline admission and alert security, the nurse manager/supervisor,

facility administration, orlaw enforcement. Especially afterregular visiting

hours, consider setting up a system to positively identify visitors, preferably

with a photo ID.

Case

Example An 8-day-old infant with an eye infection was admitted to the pediatric unit of the 

healthcare facility in which she was born. A woman entered the healthcare facility 

the afternoon of the abduction and proceeded to the pediatric unit. Upon arriving 

at the pediatric unit she informed staff members that she was the relative of a child 

who was being discharged and was there to help the mother. The “relative” had 

a large diaper bag and infant carrier. Staff members buzzed her into the locked 

unit. The “relative” had a brief interaction with a nurse and then proceeded to 

the infant’s room. The infant’s mother was not at the hospital at that time.

The “relative” was observed by the same nurse a few minutes later at the elevator, with the same diaper bag and infant carrier. The nurse became suspicious of 

the woman’s demeanor and asked a coworker to verify if the infant was still in 

her room. When it was determined the infant was gone, a code was called and 

security was notified.

The “relative” was apprehended by security and personnel in the parking lot after 

she exited the hospital and held until law enforcement arrived.

Key Factors Helping to Recover the Infant

Key factors that helped in recovering this infant included the

 Nursing staff members were alert and sensitive to the behaviors exhibited by 

the suspect. After observing the suspect as she exited the unit, they followed 

their instincts and checked the status of the infant. Upon confirming the infant 

was missing, they did not delay in calling a code and alerting security.

 Security immediately responded to the code and was able to quickly locate 

and apprehend the suspect and recover the infant.

Teaching Points

Facilities should consider setting up a system to positively identify visitors, preferably 

with a photo ID, and using it in conjunction with unit access control. See 3-2-11 

above for additional information regarding this point.

Facilities also need to take every opportunity to provide staff members, at all levels, 

instruction about protecting infants from abduction including, but not limited to, 

information about the offender profile and unusual behavior, prevention procedures, their responsibilities, and critical-incident-response plan. See 3-2-8 on page 

17 for additional information regarding this point.

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3-2-12 Require a show of the ID wristband for the person taking the infant 

home from the healthcare facility and be sure to match the numbers on 

the infant’s bands, as worn on the wrist and ankle, with the bands worn 

by the mother and father/significant other.

3-2-13 For those healthcare facilities still providing birth announcements to the 

media, NCMEC strongly encourages these facilities to reconsider their role 

in that process. Many facilities no longer provide this service and simply 

share information with the parents about how they may personally do so, 

if they wish, after advising them of the potential risks of such public 

announcements. Such advice also urges parents to use only first initials and

last names in the announcements they submit to newspapers. Be aware, if 

the healthcare facility’s public-relations department still releases birth 

announcements to the news media, no home address or other unique 

information should be divulged that would put the infant and family at 

risk after discharge. Also facilities should obtain parental consent before 

publishing an announcement in the newspaper or on the Internet. In 

addition, be aware, while giving yard signs away may be considered “good 

marketing,” the use of these signs at parents’ homes may put them at risk.

In mid-1996 some healthcare facilities began posting birth announcements 

on their Internet Web pages. These “online” announcements included photographs of the infant and in some cases of both the infant and parent(s). 

These birth announcements should neverinclude the family’s home address

and be limited to the parents’ surname(s) or first initial of the surname(s)

(e.g., S. and D. Smith or Sam and Darlene S.). Additionally the facility should 

not post this information on its Web page until after both mother and baby have 

been discharged from the facility and after the parents have signed a consent form 

for participating in this vendor service. All postings need to be activated by a 

predetermined ID or password, with no default option to circumvent this 

precaution that would enable anyone other than individuals who are 

authorized by the parents, such as family members and friends, to access 

the announcement.

3-2-14 When providing home visitation services, personnel entering patients’ 

homes need to wear an authorized and unique form of photo identification 

used only by them, strictly controlled by the issuing organization, and 

recognizable by family members. Parents need to be told about this unique 

form of ID at the time of discharge. Consider providing this information 

to the parents on the discharge instruction sheet the patient signs with the 

patient taking a copy of the discharge sheet when leaving the facility.
Consider using a system where the mother is called before the visit to 

inform her of the date and time of the visit; name of the staff person visiting;

and requirement for that staff person to wear the current, unique photo ID

badge. See 3-2-4 beginning on page 15 for a discussion of ID badges. For 

additional information about this topic see “Outpatient Areas” beginning on 

page 48.

3-3 Physical-Security Safeguards

The guidelines highlighted in bold print are considered ESSENTIAL

for the prevention and documentation every facility should

strive to meet. All other guidelines listed are highly recommended.

Guidelines for Physical Security

3-3-1 Every healthcare facility must develop a written assessment of the risk 

potential for an infant abduction.

In determining the physical-security requirements for the prevention of 

infant abduction, each healthcare facility must conduct a physical-security 

needs assessment. This assessment should be performed by a qualified

professional (e.g., Certified Protection Professional, Certified Healthcare

ProtectionAdministrator, Certified Healthcare Risk Manager) who identifies

and classifies vulnerabilities within the healthcare facility. The application

of safeguards, such as guidelines, systems, and hardware, developed by 

the facility to “harden the target” from infant abduction should be dependent upon the risk potential determined and reflect current professional

literature about infant abduction. The needs assessment should include an 

evaluation of the facility and the existing policies and procedures, together

with the possible appropriate application of any combination of physical 

controls or electronic systems such as closed-circuit television, locked and 

alarmed emergency-exit door controls, intercoms, remote door releases,

and electronic-article-surveillance (EAS) systems, sometimes called infanttagging systems. This process must be considered ongoing as targets, risks, 

and methods change, particularly in the event of new construction, with 

the written risk assessment being conducted at least on a yearly basis and 

when significant changes are identified. For assistance in this process, see

“Self-Assessment for Healthcare Facilities” beginning on page 59.

Assessments of an organization’s infant-safety program often identify

opportunities for improvements. Therefore it is important to perform 

such assessments under the auspices of the organization’s performanceimprovement (PI) program, in order to lend possible protection from legal 

discovery to such information, if and when such statutory protections 

exist. Reports and/or corrective action plans relating to findings of such

20 - For Healthcare Professionals
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assessments should also be treated as PI materials, with access limited 

to authorized persons. This is also sometimes referred to as “peer review,” 

“quality improvement,” or “quality assurance.”

3-3-2 Install alarms, preferably with time-delay locks, on all stairwell and exit 

doors leading to/from or in close proximity to the maternity, nursery, 

neonatal-intensive-care, and pediatrics units. Establish a policy of 

responding to all alarms and instruct responsible staff members to silence 

and reset an activated alarm only after direct observation of the stairwell 

or exit and the person using it. The alarm system should never be disabled without a defined countermeasure in place. A record of the alarms 

should be maintained and periodically analyzed for cause and potential 

opportunities for improvement to minimize “false” alarm activations.

Optimally, video/digital recording should be integrated into the alarm

activity. When an alarm is activated, the camera should automatically come 

to full-screen at the alarm enunciator location. This situation should be 

properly documented, a report about the incident needs to be submitted to

the proper authority within that facility, and the recorded data needs to be 

retained and reviewed by security. A monthly report needs to be generated 

and reviewed with security and nursing. See 3-4-3 on page 27 for a discussion regarding a head count of all infants. Document each false alarm, 

ascertain what went wrong, and take any necessary corrective actions. If a 

video security monitor is located at a nurses’ station, policy should specify

the purpose of that placement in such a way as to limit liability.

3-3-3 All doors to all nurseries must have self-closing hardware, remain locked 

at all times, and a staff member should be present at all times when an 

infant is in the nursery. Consider protecting nursery units in the same way 

behavioral units are protected, when possible with electronic card-in and 

card-out readers for authorized staff members and ask-in and ask-out 

for visitors.

3-3-4 If there is a lounge, locker room, or storage area where staff members 

change, leave clothing, or store scrub suits, all doors to that room must 

be under strict access control (locked) at all times.

3-3-5 Conduct and document a needs assessment for an electronic-articlesurveillance (EAS) detection system. Such a system would use an EAS 

infant-bracelet tag that is always activated and tied to video/digitalrecording

of the incident and alarm activation and integrated with electronic locking 

devices to prevent exiting when a tagged infant is in close proximity to the

exit. If a healthcare facility installs an infant EAS system, the system must

always be operational. Staff members should never adopt a philosophy of
“only turning the system on if/when they suspect a problem.” Because such

actions present major liability risks, documented records should be maintained on testing procedures and preventative-maintenance schedules.

If an electronic tagging system is employed by a facility, legitimate 

activations should be documented and a record kept. Weekly tests should 

be conducted on the electronic tagging system by way of using a randomly 

selected tag (not a test tag), and the results reported to the nurse manager, 

security manager, and proper authority within the facility. If more than one 

area (door) is covered by the system, the testing must include each individually protected area to help ensure proper operation. Monthly testing 

and documentation of the test results is essential. Realistically zero is the 

number of acceptable false alarms.

3-3-6 Install a security-camera system using recording by digital technology 

to record activity in the hallways of the unit. Cameras should be placed 

in strategic spots to cover the entrance of the unit, the nursery, hallways, 

stairwells, and elevators. Cameras should be adjusted to capture a potential 

abductor’s full face, and care should be taken to avoid strong lighting 

behind the individuals on camera. Recorders must be functional at all 

times. The recording medium must be changed or backed up daily under 

the direction of an assigned and responsible individual. Retain daily backup medium for a minimum of seven days before reusing or deleting it.

Case

Example As a new mother watched her 2-day-old daughter from her hospital bed, a woman 

portraying herself to be a nurse dressed in scrubs entered her room and asked if 

she needed any assistance. The mother stated she would like to take a shower. 

The “nurse” offered to take the infant back to the nursery and send another 

nurse to assist with the shower. The victim mother observed the “nurse” take the 

infant from the bassinet and walk out of the room. According to the mother, the 

“nurse” returned two to three minutes later with the infant and nervously claimed 

the other nurses were busy and she would return within 10 to 15 minutes. The 

“nurse” exited the room and did not return.

 Key Factors Helping to Thwart the Infant Abduction

 Key factors that helped in thwarting this infant abduction included

 The suspect did not know the infant had a security tag on her ankle, which 

prevented her from leaving the unit with the infant through an exit stairwell door.

 A nurse observed the suspect much earlier in the morning in the hospital 

solarium and then again observed the same individual lingering by a patient 

room on maternity a few hours later. This same nurse verbally challenged the 

suspect who told her she was looking for a patient and provided a specific 

name and room number.

 Another nurse observed the suspect arm-carrying the infant in the hallway in 

proximity to an exit stairwell door and made a comment to the suspect, who 

then returned the baby to the patient’s room.

22 - For Healthcare Professionals
 The detective assigned to the case advised staff members to alert other hospitals 

in the area about the incident. This action resulted in the receipt of information from two other hospitals days after the first incident that reported similar 

incidents at their facilities with a similar looking suspect.

Teaching Points

Facilities need to take every opportunity to educate parents about the procedures 

used to transport infants while in their care, especially in regard to the prohibition against “arm-carrying” infants, and the need to notify the nurses’ station 

when that procedure is violated. See 3-2-6 beginning on page 16 for additional 

information regarding this point.

Facilities also need to take every opportunity to remind staff members to 

immediately call facility security and/or other designated authority per their facility’s critical-incident-response plan when observing the behaviors exhibited by this 

suspect. See 3-4-4 on page 27 for additional information regarding this point.

Facilities also need to install and properly maintain a security-camera system. When 

images of a suspect or abductor are available, they greatly aid in the apprehension 

of suspects and the prevention of abductions or abduction attempts at other facilities. See 3-3-6 on page 22 for additional information regarding this point.

3-3-7 The camera(s) should be at/near real-time recording (versus time lapse)

and remain functioning at all times. It is further recommended (these) 

camera(s) be mounted in plain sight, at or near adult-head height, and a 

sign be prominently posted with each (all) camera(s) stating all persons 

entering the unit are being recorded for security purposes. For example

the sign could state, “Area under random video surveillance.” Some healthcare facilities have found placing a live CCTV monitor at/near the camera

showing the picture being recorded successfully replaces the signs. There 

are now integrated flat-panel monitors with built-in cameras called “Public

View Monitors” which are excellent for this purpose. These monitors are

now seen frequently in retail stores.

3-3-8 Install signage in the maternal-child-care unit; lobbies; obstetric, emergency 

room, and day-surgery waiting room areas instructing visitors they should 

not allow their children to be out of their line-of-sight.

3-3-9 Additional items to consider regarding electronic surveillance and accesscontrol equipment include

	 n	 Color cameras make identification of subjects much easier than

black-and-white cameras. There is virtually no cost difference in color

cameras today so there is no reason to use black-and-white cameras.

n Purchase and repair records should be maintained to include date of 

purchase, date of installation, date of any repairs performed, and description of work.

For Healthcare Professionals - 23
n Routine preventive maintenance should be performed as recommended 

by the manufacturer and documented.

n	 Alarms on stairwell doors should be adjusted to allow forthe maximum

delay in unlocking that is allowed by local fire regulations.

n As an aid to investigators, it is important to maintain an audit trail of 

recorded media. Tapes, if used, or digital recording should be retained as 

part ofthe facility’s retention policy as long as possible butfor a minimum

of 10 days with a goal of 30 days. Information should be contained on 

the recorded media that provides the identification of the image being

recorded to include location, date, and time it was recorded.

n Electronic systems should be fully integrated wherever possible. Alarms, 

door controls, motion detectors, elevator controls, and CCTV pictures 

can automatically be combined and presented on a single monitoring 

device that will greatly facilitate response and be supported by integrated, 

time-delay access alarms, monitored CCTV, intercoms, and remote 

release devices.

n	 Cameras covering emergency exits such as stairwells should be placed

inside the stairwell,facing the emergency-exit doorto view an adult-head

height. To save recording space on cameras in seldom-traveled areas, 

it is recommended they be equipped with motion-detection, 

activation devices.

3-4 Critical-Incident-Response Plan

The guidelines highlighted in bold print are considered ESSENTIAL

for the prevention and documentation every facility should

strive to meet. All other guidelines listed are highly recommended.

General Guidelines

3-4-1 As part of contingency planning, every facility must develop a written, 

critical-incident-response plan to respond to an infant abduction.

All protocols and critical-incident-response plans with reference to abductions of infants from the healthcare facility must be in writing. In addition 

they must be communicated to all staff members within the maternal-childcare areas and pediatrics. When these plans are part of staff training,records

must be maintained verifying attendance. Training should be performance

and competency based and documented. Other departments, including 

but not limited to security, communications/switchboard, environmental

services, accounting, and public relations, should also have written action

plans to follow in the event of an abduction. This training should begin at 

general orientation and be part of their departmental orientation competencies and annual refresher training similar to hazardous-material and 

fire training.

24 - For Healthcare Professionals
For Healthcare Professionals - 25

When formulating the critical-incident-response plan, facilities need to consider several items. Forinstance the layout or schematics and traffic patterns

differ among facilities. Review factors such as

	 n Accessibility

n	 Entrance/exit doors (both vertical and horizontal)

n Alarm systems

n	 Staffing patterns including number of staff members who are visible on

the unit

n	 Adjacent departments

n	 Proximity of unit and exits from the unit to parking areas, city streets,

and other locations where vehicles can be positioned for escape

n Coordination with local law enforcement

The plan must include a provision regarding the handling of the incident 

in relation to the time of day in which it occurs. For example if the incident

occurs at shift change, the plan must include a provision for holding the

shift scheduled to leave until excused by law enforcement or a designated

authority within the facility.

It is the responsibility of staff members to secure the facility and begin a

systematic search for the infant as quickly and completely as possible. Facility staff members must be assigned to immediately report to all exits of the

facility including areas such as doors, stairwells, and loading docks. They 

must be trained in both what to look for and what to do if they suspect an 

individual entering their assigned area may present the ability to conceal 

an infant in an attempt to depart the healthcare facility.

	 The plan must include a provision to designate a staff person, usually the

security director, to act as the liaison with law enforcement. It is important 

to considerthe healthcare facility’s protocol for TJC sentinel-eventreporting.

In addition details about code words and drills that need to be considered 

when formulating or updating a plan are below.

Using a code word (Code Pink strongly recommended), to alert facility 

personnel there is a missing infant, is essential as part of the facility’s critical-incident-response plan in the event of an infant abduction (patient and 

nonpatient). Code Pink is becoming an industry-standard practice among 

healthcare organizations to use forthis code. Periodically quiz staff members

about their knowledge of this code word and their responsibilities when the 

code is used. Healthcare facilities in each community should standardize 

the code word used within their community. Code words currently used 

by law enforcement and retailers such as AMBER Alert, AMBER, and Code 

Adam should be strictly avoided to represent infant abductions or missing 

children in the healthcare setting.
Conduct at least one unannounced, facility-wide, infant-abduction drill 

each year involving all facility personnel taking into account more than 

one drill may need to be held in order to include personnel who work day, 

evening, weekend, and/or nontraditional shifts. In addition to the facilitywide drill, facilities should conduct quarterly unit-specific drills, “tabletop”

exercises, or audit-type exercises. Critique each exercise to identify

opportunities for improvement to enhance policy, procedure, or performance standards. Tabletop exercises take place “around the table” with the

principle players acting out a specific scenario generally without simulated

or actual patients involved. An audit-type exercise may be a formal review

of a procedure by actually walking through the procedure or “testing” a 

procedure. An example of testing a policy/procedure would be sending a

staff person, without the proper identification, into a mother’s room and

advising the mom that her baby is being transported out of the room for a 

given purpose. If mom releases the infant to the caregiver, without asking 

for the proper badge identification, the caregiver should first reinstruct the

mom supportively. The exercise itself should indicate the need for the facility to change or improve mother education.

	 Law enforcement should be advised, and/or invited to participate, in

advance of all facility-wide drills to avert any unnecessary response should 

an employee, patient, or visitor take the initiative to call law enforcement 

during the drill.

For additional information about drills and the evaluation of them, see

Security Issues For Today’s Health Care Organization listed in the “Bibliography” 

on page 82 in the 2002 entries. Also see “Drill Components” on page 38 and 

“Drill Critique Form” beginning on page 39. These items were adapted from 

information designed by Connie Blackburn Furrh of Cimarron Insurance 

Exchange and reprinted with her permission.

3-4-2 Call NCMEC at 1-800-THE-LOST® (1-800-843-5678). NCMEC is in an 

excellent position to advise, provide technical assistance, network with other

agencies and organizations, assist in obtaining media coverage of the abduction and activation of emergency alert systems, coordinate dissemination of 

the infant’s photograph as mandated by federal law (42 U.S.C. § 5773), and 

provide support for victim families.

With the approval of law enforcement, a media or crisis communication plan 

should be developed to brief the media about the incident; enlist their aid in 

publicizing the abduction; promote the dissemination of accurate descriptive 

information about the infant and abductor; coordinate photo dissemination; 

and provide appropriate access to victim parents while protecting their privacy. It is imperative all media releases be coordinated with the attending

law-enforcement agency. The key to achieving the safe return of the infant 

is often through the cooperation of the public and, many times, specifically

26 - For Healthcare Professionals
For Healthcare Professionals - 27

through the cooperation of the abductor’s family members or associates. A

concerted and well-thought-out media plan is critical in this process.

Nursing Guidelines

3-4-3 Immediately search the entire unit. Time is critical. Do a head count of 

all infants. Question the mother of the infant suspected to be missing as 

to other possible locations of the infant within the facility. If the count 

is reconciled, the accountable person calls an “all clear.” Records should 

be maintained reflecting how each infant-alarm activation was resolved or

reconciled, by whom, at what time, and on what day.

3-4-4 Immediately and simultaneously call facility security and/or other designated authority per your facility’s critical-incident-response plan.

This includes the announcement of the incident to all staff members using

the predesignated code word (see the section of 3-4-1 addressing code words 

on page 25) and immediate notification of the local law-enforcement agency.

Make sure the law-enforcement agencies that frequent your facility, for such 

things as assaults and car accidents, know this code word.

Where a facility has no security staff, immediately call the local 

law-enforcement agency, and make a report. Then call the local FBI office

requesting assistance from the squad handling crimes that are committed

against children.

Case

Example A woman presented herself to the victim mother at the healthcare facility, as a 

volunteer from a church who could assist in obtaining supplies for her infant. During 

the conversation the “volunteer” asked the victim mother to complete forms that 

included requests for information such as name, address, and telephone number. 

The “volunteer” left, and the mother and infant were later discharged.

Two weeks later the “volunteer” arrived unannounced at the victim mother’s home 

and offered to drive her to the church to get some of the free supplies. The victim 

mother declined the offer on that day; however, she agreed to accompany the 

suspect the next day. On the next day they met and walked to a park 

approximately five blocks from the home bringing along the infant. A rose-colored 

minivan was in the parking lot at the park. Once there the suspect informed the 

mother they were waiting for someone else to arrive and suggested the mother 

cross the street, go to a store, and purchase soft drinks. The mother agreed to 

leave her son with the suspect and went to make the purchase. Upon her return, 

the victim mother discovered the woman, the minivan, and her son were gone. 

The victim mother flagged down a passing law-enforcement officer, and shortly 

thereafter a statewide AMBER Alert was issued providing a description of the van 

and a composite sketch of the suspect.
28 - For Healthcare Professionals

The next day law enforcement released video-surveillance images of the suspect 

as captured when the suspect visited the healthcare facility, but no pictures of 

the infant were available. The suspect was positively identified from those images. 

Tips eventually lead officers to the suspect’s home where the baby was 

safely recovered.

Key Factors Helping to Recover the Infant

Key factors that helped in recovering this infant included

 Law enforcement was able to retrieve videotaped images of the suspect from 

the healthcare facility two weeks after the birth of the infant

 Law enforcement quickly issued an AMBER Alert with a composite of the 

suspect and a description of the vehicle

 Public response to the AMBER Alert was swift and positive

Teaching Points

Facilities need to take a color photograph or color video/digital image of the infant 

and footprints of infants prior to the removal of a newborn from the birthing room 

or within a maximum of two hours of the birth. Such photos and footprints can be 

invaluable in recovering and identifying an abducted infant. See 3-2-3 beginning 

on page 14 for additional information regarding these points.

Facilities need to take every opportunity to educate parents about ways to prevent 

infant abductions. Such should include consideration of providing information 

about the services offered by the healthcare facilities and any affiliated organizations. See 3-2-7 on page 17 for additional information regarding this point.

Facilities also need to take every opportunity to provide staff members, at all levels, 

instruction about protecting infants from abduction including, but not limited to, 

being alert for unusual behavior. See the discussion about this concept beginning 

on page 10 of section 3-1 for additional information regarding this point.

Facilities also need to take every opportunity to remind staff members at all levels 

to immediately call facility security and/or other designated authority per their 

facility’s critical-incident-response plan when observing such behaviors. See 3-4-4 

on page 27 for additional information regarding this point.

3-4-5 Secure and protect the crime scene, which is the area where the abduction 

occurred, and allow no one entrance until law enforcement releases it, in 

order to preserve the subsequent collection of any forensic evidence by 

law-enforcement officials. Since interviews with all persons on the unit 

during the incident are of great importance to the investigation, staff 

members should remain on the unit until permitted to leave.

This duty should be relinquished to security upon their arrival and subsequently to law enforcement upon their arrival.
3-4-6 Move the parents of the abducted infant, but not their belongings, to a private 

room off the maternity floor. The room, furnishings, and all items within the

room, including patient possessions, should be untouched pending possible 

forensic processing by law enforcement.

Have the nurse assigned to the mother and infant continue to accompany 

the parents at all times, protecting them from stressful contact with the 

media and other interference. Secure all records/charts of the mother and

infant, and check for adequate documentation. Notify lab and place STAT 

hold on infant’s cord blood and any other blood specimens for follow-up

testing. Consider designating a room for other family members to wait in. 

Such will give them easy access to any updates in the case while offering

the parents some privacy. Also consider designating a room for media and 

another one for law enforcement.

Following relocation of the parents of the abducted infant from the unit, the 

facility should

n	 Coordinate services to meet other emotional, social, and/or spiritual

needs of the family

n Provide regular, ongoing, informational updates, in collaboration with 

other entities such as law-enforcement personnel

Note: Such communications with the family following this type of 

unanticipated outcome should be consistent with the organization’s disclosure protocol.

3-4-7	 The nurse manager/supervisor should brief all staff members of the unit.

In turn, nurses should then explain the situation to each obstetric patient/

mother while the mother and her infant are together. Mothers should never 

hear this news from the media or law enforcement. The nurse manager/

supervisor should also be available to liaise with law enforcement. The 

nurse manager/supervisor should remind staff members not to discuss the

incident with the media. The two other areas in the facility greatly affected

are medical records and Human Resources because both departments are 

asked to produce a great deal of documentation.

3-4-8	 Astaff person, preferably the nurse assigned to the mother and infant, should

be assigned to be the primary liaison between the parents and facility after

the discharge of the mother from the facility.

3-4-9 Nurse managers/supervisors must be sensitive to the fact nursing staff 

members may suffer posttraumatic-stress disorder (PTSD) as a result of 

the abduction, and make arrangements to hold a group discussion session 

led by a qualified professional as soon as possible in which all personFor Healthcare Professionals - 29
30 - For Healthcare Professionals

nel affected by the abduction are required to attend. Employee assistance 

programs, critical-incidence stress debriefings, and/or spiritual/“pastoral” 

care should be available. Efforts should be made to provide ongoing 

counseling for individuals who need it.

Such a session will allow healthcare-facility personnel a forum for expressing their emotions and help them deal with the stress resulting from the 

abduction. During this group session,reinforce the directive that staff members are not to communicate with the media about the abduction incident 

reminding them all media communication should be from the designated 

law-enforcement spokesperson/healthcare public-relations representative.

Organizations with employee assistance programs may refer affected staff

members to such services.

Discussion of case details should be limited to individual information sharing 

with appropriate law-enforcement authorities, security, and/or designated

risk management/quality improvement staff members/committees and/or

assigned claim/legal defense counsel. Staff member participation in criticalincident debriefing activities and/or counseling sessions should focus on

obtaining emotional support rather than disclosing case details.

Care should be taken not to discuss case details before any criminal/civil

trials are concluded. Individual information-sharing-disclosure of case 

details should be limited to law-enforcement authorities and security, PI, and 

office of risk management authorities. Certain staff members may require

further assistance to psychologically integrate this incident and return to 

their duties on the unit. Facilities should make every effort to assist these

staff members with this process.

Consider inviting the investigators of the law-enforcement agencies handling 

the case while emphasizing feelings, not details about the abduction, are the 

only things to be explored in these sessions.

Note The National Center for Missing & Exploited Children is an important resource for 

assessing and consulting about PTSD among staff members. Individual healthcare 

facilities are often so overcome with the enormity of the abduction event itself it is 

hard to see past the moment to recognize the signs and symptoms of PTSD in their 

staff members. It seems unimaginable to realize staff members suffering from PTSD 

have to continue working, encourage laboring mothers in bringing forth new life, 

and soothe away their patients’ fears of this crime. This is their job, but whose job is 

it to soothe away the nurses’ fears and ease their crushed spirits so they may do their 

jobs? This time of healing should be strongly encouraged. The result of doing nothing 

can be a destruction of wonderful professionals. Help from NCMEC is a telephone 

call away. Nurse managers should not misjudge the intensity of the emotional storm 

that can rage within nurse victims after an abduction event and call 1-800-THE-LOST®
For Healthcare Professionals - 31

(1-800-843-5678) for assistance with this healing process after an infant abduction in 

their facility.

Connie Blackburn Furrh, RN, Vice President, Risk Management, Cimarron Insurance Exchange.

Security Guidelines

3-4-10 Upon notification an infant is missing, security needs to

n Immediately and simultaneously respond to perimeter points of the 

grounds or campus of the facility to observe persons leaving and 

record vehicle license-plate numbers. After securing the perimeter, 

proceed to the location of the incident, and activate a search of the 

entire healthcare facility, interior and exterior. Time is critical.

n Call the local law-enforcement agency, and make a report. Then call 

the local FBI office to report the incident to the squad handling crimes 

committed against children.

n Assume control of the crime scene, which is the area where the abduction occurred, until law enforcement arrives.

n Assist the nursing staff in establishing and maintaining security within 

the unit (i.e., access control to the unit), and notify public relations.

n Secure videotapes/digital recordings for seven days prior to the incident, and request the same from other healthcare facilities in the area 

and adjacent business.

n Given the speed with which electronic technology changes, it is possible 

the electronic recording equipment in the healthcare facility will not 

be compatible with that of law enforcement. Facilities should provide 

access to equipment and a private location where law-enforcement 

officials may review the recorded electronic images.

Ask law enforcement to dispatch an officer to the scene using only the

standard crime-code number over their radio without describing the 

incident. This will help deter media and others who are listening to lawenforcement channels on scanners from being alerted about the incident 

before appropriate law-enforcement procedures are initiated. Also make 

sure the law-enforcement agency knows where in the facility (unit specific)

to respond.

3-4-11 In order to safeguard against “panicking” the abductor into abandoning 

or harming the infant, follow the facility’s media plan, which should 

mandate all information about the abduction is cleared by facility and 

law-enforcement authorities involved before being released to staff 

members and the media.
Most often infants are recovered as a direct result of the leads generated by

media coverage of the abduction when the abductor is not portrayed in the 

media as a “hardened criminal.”

	 Consider limiting official spokespersons to one healthcare-facility staff

person, preferably from public relations, and one law-enforcement representative. These persons should be on the premises or on call throughout 

the crisis.

3-4-12 Brief the healthcare-facility spokesperson, and then that spokesperson can 

inform and involve local media by requesting their assistance in accurately 

reporting the facts of the case and soliciting the support of the public. Be 

as forthright as possible without invading the privacy of the family.

The family should be apprised of the media plan and their cooperation 

sought in working through the official spokespersons.

3-4-13 Call NCMEC at 1-800-THE-LOST® (1-800-843-5678) for technical assistance 

in handling ongoing crisis management.

3-4-14 Newborn nurseries, pediatrics units, emergency rooms, outpatient clinics 

for postpartum/pediatric care at other local healthcare facilities, and the 

health department’s bureau of vital statistics should be notified about the 

incident and provided a full description of the infant and suspected or 

alleged abductor.

As part of her plan, the abductor may take the infant to another facility, a 

private physician, or a public agency in an attempt to have the baby “checked

out,” obtain a birth certificate for “my baby who was delivered at home,”

or secure public assistance.

3-4-15	 As part of the facility’s overall annual security program review, as required

under TJC standards, document a specific review of the infant-security and

safety program through use of the self-assessment tool beginning on page 

59, or through the use of the certified individual as described in 3-3-1 on

page 20.

Law-Enforcement Guidelines

Law enforcement should treat a case of infant abduction from a healthcare facility 

as a serious, felony crime requiring immediate response.

3-4-16 Enter the infant’s name and description in the FBI’s National Crime 

Information Center’s Missing Person File (NCIC-MPF). If the abductor 

32 - For Healthcare Professionals
is known and has been charged with a felony, cross-reference the infant’s 

description with the suspected abductor in the NCIC Wanted Person File.

3-4-17 Call NCMEC at 1-800-THE-LOST® (1-800-843-5678). NCMEC is in an 

excellent position to advise, provide technical assistance, network with 

other agencies and organizations, assist in obtaining media coverage of 

the abduction, and coordinate dissemination of the infant’s photograph 

as mandated by federal law (42 U.S.C. § 5773).

Parents or law-enforcement authorities may request age-progression of the 

infant’s photograph as time elapses on the case.An infant’s photograph may

be “aged” using earlier photographs, computer technology and graphics, 

data about facial development, and the special skills of medical illustrators. 

(See examples on pages 36 and 37).

3-4-18 Call the local FBI office requesting the Crimes Against Children (CAC) 

Coordinator. The CAC Coordinator can request assistance from the FBI’s 

National Center for the Analysis of Violent Crime. They can provide technical and forensic-resource coordination; computerized-case-management 

support; investigative, interview, and interrogation strategies; and information about behavioral characteristics of unknown offenders.

3-4-19 Immediately secure and review any available videotapes/digital disks 

from the abduction scene and contact all other birthing facilities in the 

community and adjacent businesses to request the retrieval and secure 

storage of the previous seven days’ worth of videotapes/digital disks 

for review. These videotapes/disks should be treated as photographic 

evidence. Given the speed with which electronic technology changes, it is 

possible the electronic recording/viewing equipment within a law-enforcement agency may not be compatible with that of the healthcare facility. 

Law-enforcement officials should ask for access to the facility’s equipment

and review the recorded images in a private location within the facility.

3-4-20	 Consider setting up one dedicated local telephone hotline for sightings/leads

or coordinate this function with a local organization.

3-4-21	 Polygraphs may be useful with female offenders and their male companions. While polygraphing the baby’s father may be useful for eliminating

him as a suspect, it should be done early in the investigation. Be aware that 

polygraphing the baby’s mother within 24 hours of the delivery, or while

medicated, is ill-advised.

3-4-22 To deter future crimes and document criminal behavior, the abductor 

should be charged and every effort made to sustain a conviction.

For Healthcare Professionals - 33
3-4-23 Any release of information concerning an infant abduction should be well 

planned and agreed upon by the healthcare-facility and law-enforcement 

authorities involved. Care should be taken to keep the family fully 

informed. Consider designating one law-enforcement official to handle

media inquiries for all investigative data. All media releases should focus 

on the safe return of the infant, not the arrest/conviction of the abductor.

Public-Relations Guidelines

3-4-24	 As soon as possible after the abduction, contact the local media and request

they come to a designated media room at the healthcare facility to receive 

information about the abduction. The media should be provided with the 

facts as accurately as possible, asked to request the assistance of the public 

in recovering the infant, and asked to respect the privacy of the family. 

Public-relations professionals should be forthright with the media, but 

make certain to release only information approved by the law-enforcement 

authority in charge of the investigation, limit sharing too much information about security procedures and technology in place within the facility, 

and refrain from blaming the victim parent in cases in which a parent may 

have handed their child to someone posing as a staff member within the

facility. Press releases should be prepared and presented jointly by the lawenforcement, public-information officer, and the healthcare media liaison.

Most often infants are recovered as a direct result of the leads generated by media 

coverage of the abduction.

Place a news release on the facility’s website regarding the abduction as a

quick place for the media and public to find information about the case.

Doing this may reduce the number of calls the facility’s switchboard receives.

Designate a separate area where friends and family of the parents can 

gather to receive regular updates about the abduction in order to keep them 

informed about the case and shielded from the press. Designate a separate 

area for the media to gather. Provide the media escorted opportunities to 

film “an OB/nursery” area or personnel.Advise staff members to be alert for

possible rogue reporters who may attempt to obtain confidential information from staff members not authorized to offer such and/or gain access to

areas of the facility not accessible to them.

3-4-25 Provide switchboard staff members with a written response or forwarding 

information they may use for outside callers including anxious parents 

who are planning to have their infants delivered at that facility and persons calling with tips or information about the abduction.

34 - For Healthcare Professionals
3-4-26 Activate the crisis communication plan and/or the facility incident command center that should list steps to be taken, people to be notified, and 

resources available such as photo duplication and dissemination. This 

should include dissemination of information to staff members before they

go off duty.

For additional information about planning for, creating, and responding to 

a critical-incident plan, see James T. Turner’s 1990 article listed in the “Bibliography” on page 78.

Sample Notification Form

TO: AREA BIRTHING FACILITIES

RE: Unusual/Suspicious Activity

FROM:

Following is a description of an unusual/suspicious incident that occurred at our facility. Please 

inform us if you experience any incidents of this nature.

Occurrence Date(s) Time(s)

Description of Subject

n Name/Alias(es)

n Sex

n Approximate Age

n Race

n Height

n Weight

n Hair

n Eyes

n Clothing

n Unusual Characteristics

Synopsis of Incident

For additional information contact at ( )

List facilities notified including specific contacts made and date and time of contact.

National Center for Missing & Exploited Children notified? Y N

If not, please contact at 1-800-THE-LOST® (1-800-843-5678).

For Healthcare Professionals - 35
36 - For Healthcare Professionals

Original and 

age-progressed 

photograph of 

Andre Bryant 

who was abducted 

from his home 

in March 1989.

Nonfamily Abduction

Andre’s photograph is shown age progressed to 15 years. He was last seen with his mother, who was later found deceased. Andre and 

his mother had left their residence at about 2 p.m., to go shopping with two black female acquaintances in a burgundy Pontiac Grand 

AM, possibly with Maryland tags. 

Sample crib card as provided by Mead Johnson Nutrition.

ANDRE BRYANT Age Progressed

DOB: Feb 17, 1989

Missing: Mar 29, 1989

Age Now: 19

Sex: Male

Race: Black

Hair: Black

Eyes: Brown

Height: 1’7” (48 cm)

Weight: 10 lbs (5 kg)

Missing From:

BROOKLYN

New York

United States

Anyone Having Information Should Contact

NATIONAL CENTER FOR MISSING & EXPLOITED CHILDREN

1-800-THE-LOST (1-800-843-5678) or

New York City Police Department (New York 1-212-694-7781)

Congratulations!

My Name Medical Record #

Sex My Birthdate Time Rm

Birth Weight lbs. oz. Length in. Head Chest

Mother's Doctor

My Doctor
For Healthcare Professionals - 37

Photo composite of 

Tavish Sutton who 

was abducted from 

his hospital room 

in March 1993.

Anyone Having Information Should Contact

NATIONAL CENTER FOR MISSING & EXPLOITED CHILDREN

1-800-THE-LOST (1-800-843-5678) or

Atlanta Police Department (Georgia) -

Missing Person Unit 1-404-853-4235 Or Your Local FBI

The pictures shown are “PHOTO COMPOSITES” of what Tavish may have looked like at age 4 and what he might look like at age 14. 

Tavish was abducted from his hospital room at Grady Memorial Hospital in Atlanta, Georgia, sometime between 6:45 and 7:00 a.m.

on Tuesday, March 9, 1993.

Nonfamily Abduction

TAVISH SUTTON Age Progressed

DOB: Feb 10, 1993

Missing: Mar 9, 1993

Age Now: 15

Sex: Male

Race: Black

Hair: Black

Eyes: Brown

Height: 2’0” (61 cm)

Weight: 8 lbs (4 kg)

Missing From:

ATLANTA

Georgia

United States
Drill Components

n At least once a year an infant abduction drill should be conducted including the entire 

facility not just obstetrics

n Prior to the drill those who will observe and access the drill should attend a training class

n Training classes should include

l Review of physical security features in place

l Review of critical-incident-response plan

l Planned scenario of abduction

n Drills should commence with an alarm sounding or by handing someone a note within the 

birthing center explaining a baby has been abducted

n Observers should be chosen from all job levels

n There should be standardized drill reports

n Law enforcement should be informed it is a drill only

n Observers should provide “real-time” instruction during the drill if needed

n At drill conclusion the evaluation form should be forwarded to the Security Director and/

or other appropriate designee

n Evaluation meeting should include mid- and senior-level management

n During evaluation process, with observers and staff members involved in the drill in 

attendance, review step-by-step to identify areas needing improvement

n Final drill reports should include what did and did not work and a plan of action 

for improvements

n Final reports should be sent to Administration and the obstetric unit within two weeks of 

drill completion

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Drill Critique Form

Date Time Yes No NA Descriptors Name

What time was the discovery made?What time was the Nurse Manager notified?What time was Security called?What time was Law Enforcement notified?What time was Administration notified?Who notified Administration?What time was the facility Operator notified to

call a Code Pink Drill?

Does PA system reach all areas of the healthcare facility?Are some areas too noisy to hear PA announcements?Who was assigned to stay with the nurse who discovered

the missing infant?

Who was assigned to stay with the mother of the missing infant?Were patients alerted a drill was in progress?What parts of the prevention-of-infant-abduction plan were affected?n Did someone manage to breech the security entrance?n Was someone carrying a baby in his or her arms?n Were OB staff members wearing visible ID badges?Did abductor have a “visitor” badge?Were all egresses, as identified in prevention plan, monitored?Was search of entire OB unit accomplished?Were the rest of the infants accounted for?Were trash cans searched?Were suspicious persons approached/followed?Suspect descriptionn Agen Racen Eye colorn Weightn Height
40 - For Healthcare Professionals

Date Time Yes No NA Descriptors Name

Anything unusual about the person such as a limp?Description of suspicious carn Maken Modeln Colorn Yearn Tag numbern Anything unusual about car?Direction of travel for any suspicious carDid all staff members stay on duty until end of the drill?Was a staff member assigned to the “crime scene” so

it was not disturbed?

Was infant’s picture, medical records, and blood specimen secured?Was a temporary Command Center set up in the department

of concern?

When was the National Center for Missing & Exploited Children notified?Who notified the National Center for Missing & Exploited Children?When was the FBI notified?Who notified the FBI?When was the security tape retrieved for evidence?Who retrieved the tape?Was drill realistic?Did staff members perform according to protocol?What time were other birthing facilities in area notified?What was the length of the drill?What time was the “all clear” sounded?What time were periphery guards notified?When were drill evaluations submitted?
For Healthcare Professionals - 41

4. Liability

Note: The information cited in this section is based on anecdotal information learned 

by NCMEC staff members and does not necessarily represent an analysis of all

claims associated with infant abductions from healthcare settings. The comments

herein should not be construed as or substituted for specific legal advice.

A comprehensive program of healthcare policy, including education of and 

teamwork by nursing, parents, security, and risk management as well as various 

elements of physical and electronic security enhancements, helps the position of 

a healthcare facility should an abduction occur. In the cases litigated, damages 

awarded against a facility generally have been mitigated when a healthcare facility 

has had the foresight to proactively reduce abduction risks.

In the cases studied so far of the healthcare facilities that have been sued, as 

a result of infant abductions, a higher percentage of suits occurred in those cases 

where the infant was not recovered within one week of the abduction. The likelihood 

of litigation did not vary based on the location of the abduction. That is, families 

sued those facilities in equal proportions whether the infant was abducted from 

the nursery, the mother’s room, or a pediatric room. The facility was more likely to

be sued in cases where the abductor impersonated facility staff members than in

those cases where the abductor did not impersonate staff members.

In cases of infant abduction, a healthcare facility is potentially liable on two 

grounds. The first is based on its general duty to take reasonable care to prevent

the occurrence of foreseeable harm to its patients. The healthcare facility could be 

liable for any physical or psychological harm suffered by the abducted infant.

	 The second area of liability is based on the healthcare facility’s contractual duty

to use reasonable care to prevent the occurrence of foreseeable injury to third parties. Thus the healthcare facility could be liable to the parents for the costs of any 

searches and psychological harm.And this liability could extend to abductions from

settings other than the healthcare facility after the infant’s discharge if the abductor

obtained information about the victim family from the healthcare facility that aided 

in the abduction.

Another area of liability concerns the need for obstetric/pediatric physicians, especially 

those in group practice, to have photo IDs to identify themselves to mothers (e.g., on-call 

physicians who may not be known to the family and/or staff members) or to be introduced 

to the mother by the nurse responsible for their care.

	 Today’s administrators, risk managers, and security directors have the duty

and responsibility for guiding not only the public trust in their facility but also the 

patient’s safety and staff awareness for potential events. In addition, as noted on

page 10 in section 3-1, to create a justifiable and defensible posture, each facility

should use a multidisciplinary team to conduct a self-assessment, using the form 

beginning on page 59, and note how they meet these guidelines or document what 

is not applicable to their facility and why. Once this assessment step is completed 

facilities should use the outline created to review and modify their policies and 
procedures as needed based on the format of these national guidelines. The 

liability to a facility regarding an infant encompasses many aspects that go beyond 

potential out-of-pocket expenses during an event and settlements awarded to family members from any resulting lawsuits. Facilities need to consider expenses such

as potential loss of faith of patients within the area to continue using their facility 

for OBGYN or other services and the negative impact on staff members on duty

during an incident up to and including loss of staff members and training of

replacement staff members. Facilities also need to weigh the costs of those potential

expenses against the cost of improving security and facility readiness in order to

reduce the risk of an abduction incident in their facility. One tool that may assist in 

this process is a Hazard Vulnerability Analysis (HVA). Per TJC’s Environment of

Care Standard EC.4.11.2, hospitals conduct an HVA (emergency management and 

security management) to identify events that could affect demand for its services

or its ability to provide those services, the likelihood of those events occurring, and 

the consequence of those events. Before making changes if an abduction has 

occurred, please contact NCMEC at 1-800-THE-LOST® (1-800-843-

5678) for guidance.

Though infant abductions do not occur with high frequency in any given area, 

they do occur. Given the statistics and known information from this publication 

and the other professional sources summarized in the “Bibliography” beginning on 

page 77, ignoring the potential for infant abduction — especially with the special 

protections due to infants in adoption proceedings, “legal hold,” and guardianad-litem situations — negates the prudent due diligence of risk managers, nurse 

managers, and healthcare security necessary for them to perform their jobs. The

foreseeability of a particular infant-abduction incident may vary given the totality 

of circumstances. Considering the volume of material published in professional 

and popular literature, however, there is wide agreement foreseeability affixed to

the healthcare industry nationwide beginning in January 1992. The “Bibliography” 

outlines, in chronological order, the benchmark articles in journals and publications

for healthcare professionals.

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5. After Discharge/Transfer from

a Maternal-Child-Care Unit

After discharge from a maternal-child-care unit, most newborns go home with their

families; however, all infants need follow-up care whether in a special-care-nursery 

situation immediately after birth orforregular check-ups. This chapter offers advice

to healthcare professionals about helping to safeguard infants and children during 

such times of follow-up care whether at home, at a regular check-up, or when in a 

healthcare facility for either a short or prolonged stay.

Infant-security policies and procedures should be consistent throughout a 

healthcare facility from the maternal-child-care unit to special-care nurseries to the 

pediatric unit to outpatient areas. All items contained in Chapter “3. Guidelines 

for Healthcare Professionals,” beginning on page 9, should be carefully considered 

for implementation in areas of the healthcare facility where infants will be located 

because consistency of policies, procedures, training of staff members, and security

protocols will help ensure compliance, better safeguard infants and children when

in any area of the facility, and be closely scrutinized if an incident is litigated.

	 When admitting and discharging infants and children to these areas of the

healthcare facility

n Footprint, photograph, and take a blood or saliva sample for DNA purposes of all infants 

aged birth to 3 months as well as a thumbprint of the infant’s mother.

n Perform and record a full, physical assessment noting any unique features. The 

footprints, photograph, and physical assessment must be placed in the infant’s

or child’s medical chart. Overtime refootprinting is advised, but certainly before

discharge. For instance if children stay longer than one month, they should be 

photographed and refootprinted monthly. The blood sample must be saved until 

at least one day after the infant’s or child’s discharge.

n As discharge nears, parents may use a rooming-in service to prepare for meeting 

the infant’s or child’s special needs at home. It is imperative security procedures

be followed that stress the importance of line-of-sight supervision by parents 

in these rooming-in situations.

n Upon discharge, require a show of the ID wristband for the person taking the 

infant home from the healthcare facility, matching the bands on the wrist and 

ankle of the infant with the bands worn by the mother and father or significant

other. If parents do not have identification bands, require verification of identification with an official photo ID (e.g., driver’s license).

To better safeguard the infant or child while being transported within the

healthcare facility, personnel must see that

n All healthcare-facility personnel authorized to transport infants and children should wear 

conspicuous, color-photo IDs as described in Guideline 3-2-4 beginning on page 15.

n Only personnel authorized to transport infants and children or a person with an 

authorized ID band for that infant or child is allowed to transport children as described 
in Guideline 3-2-5 on page 16. In cases where the infant or child needs to be taken 

for tests in other units of the facility (i.e., X-ray, MRI) staff members should tell

parents the transporter is an employee of the facility and parents should be 

encouraged to accompany their infant or child if and when possible. The facility should consider giving infants and children priority for testing to decrease 

their waiting time in the other unit. Transporters, who accompany infants and 

children, should receive education in abduction prevention and infant-security 

policies and procedures. Facilities with an electronic tagging system in maternity 

units should consider tagging all infants and toddlers, who are younger than 2, 

and any child on “police or child-protective-services hold.” For details about 

use of electronic tagging systems, see 3-3-5 beginning on page 21.

n Infants and children are transported one at a time and never left out of direct, lineof-sight supervision.

n Infants and children are never carried, but always pushed in/on a bassinet, crib, stretcher, 

or wheelchair.

n Anyone visiting with or transporting the infant or child, who is not an authorized staff 

member, including the mother, father, or any other person designated by the parents, is 

required to wear an ID wristband or produce an official photo ID. All matching wristbands should be coded alike numerically and readily recognizable. This process 

needs to be clearly documented, especially to facilitate discharge of the infant or 

child. Identification policies should clearly outline steps to be implemented for

reapplying matching identification bands when the mother has been discharged

from the facility but the infant is still in the facility.

n	 Infants and children who cannot be in direct, line-of-sight by staff members

or parents, when possible, are placed in rooms physically located away from 

stairwells and elevators. Children involved with custody or abuse issues should 

receive greatest priority for this room placement, and security should be notified of their high-risk status. The person admitting an infant or child should be

discreetly questioned regarding any custody issues and any positive history 

documented in the medical record.

n An access-control policy is established for these areas of the healthcare facility to maximize 

safety. All exterior doors to the unit where infants and children are staying must

have self-closing hardware and be under strict access control (locked). Healthcare 

facilities should consider the use of alarms and security cameras on these doors. 

At the front lobby or entrance to the unit, instruct healthcare-facility personnel 

to ask visitors which infant or child they are visiting and their relationship to 

the patient. If no name is known or given, decline access and alert security, the 

nurse manager/supervisor, the facility administration, and/orlaw enforcement.

Set up a sign-in log for visitors to the unit, specifying the infant or child to be 

visited, and requiring the visitor to show an official photo ID.

n If an infant or child is missing from one of these units, activate the criticalincident-response plan. That activation should include the use of a different

or modified code word from the one used for infants taken from the maternalchild-care unit. See the text regarding code words on page 25.

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Special-Care Nurseries

Neonatal and Pediatric-Intensive-Care Units (N/PICUs) typically consist of large

rooms with multiple bassinets where parents may not be constantly in the unit 

until the infant’s discharge. In addition these units generally do not often utilize

the same level of security as employed in well-newborn nurseries due to continuous monitoring and increased nurse-to-patient staffing ratios. There is, however,

a current trend toward “pod” designs where four or five infants are cared for in

smaller rooms and parents spend more time at the bedside. Staff members must

be vigilant in these situations especially when family members other than parents 

are allowed to visit without the parents also being present.

Because parents often spend quality, one-on-one time with their child while in

these units, each family member should be positively identified and documented

by nursing staff members. Consideration should be given to using multipart patient

ID bands for parents or some otherform of identification and unit-pass system to be

used by family members and visitors approved by the parents. Visitors approved 

by parents must be carefully observed and not allowed near any other infants.

While there has been only one reported case of a nonfamily-member infant 

abduction from NICUs, a number of infant abductions from these units have 

occurred involving family members of infants who were on “court hold” for such 

reasons as positive drug screens and custody issues; infants awaiting adoption; 

and guardian-ad-litem situations. While these abductions may be reported to 

local authorities, no national figures have been systematically tabulated about

the incidence of this crime as committed by family members. Implement a policy

and procedure meeting the security needs of an infant who is on “court hold.” 

For example if the mother and/or father/significant other is in the well-newborn

nursery or NICU to visit the infant, the parent(s) should be under close and direct 

supervision and observation at all times. Special attention should be exercised if

an “emergency,” such as a fire alarm or bomb threat, occurs in another part of the

facility. Associates of perpetrators may stage a ruse to distract or otherwise engage 

security and supervisory staff members while another family member attempts

an abduction.

It is imperative that the assessment be used to identify any variations in security 

protocols for inpatient infant and pediatric unit(s) to demonstrate a reasonable and 

appropriate protection process.

Infant-security-risk issues in such special-care units are multifaceted and may 

include but are not limited to

n Infant-care procedures that result in numerous infant-identification-band

changes due to reinsertion of intravenous needles, edematous extremities, or

infant-weight gain. The removed ID bands should be stapled to the medical 

record or cut and placed in the “sharps box” noting this and the ID band number in the medical record. NICU infants then need to be rebanded with another 

identification band.
n Environmental designs that divide the NICU into small, low-census pods. These 

areas may be difficult for line-of-sight observation of infants at all times, especially in “rooming-in” situations, and may result in lower staffing patterns.

n Security policies and procedures that may not be consistent with the maternity 

department (e.g., discharge of baby directly from unit where parents carry the 

baby out of the facility in their arms).

n Large, busy units with multiple caregivers who may not be familiar with 

the parents.

n Use of temporary agency orregistry personnel/traveling-nurse-service personnel who are not required to wear photo or unique identifying badges that are 

monitored each shift.

n Smaller units may experience, at times, lower census and lower staffing patterns

that may increase vulnerability for direct, line-of-sight observation.

n Discharge process that does notrequire parents to present an identification band

matching the infant’s or require verification of identification with an official

photo ID.

n	 A false sense of security, on the part of staff members, that an infant abduction would not occur in such special-care units (e.g., probable targets would 

be “feeder and grower” babies, babies ready for discharge, “boarder” babies, 

or “adoption” babies who have yet to be placed with a family or picked up by 

the adoptive family). Facilities with electronic tagging systems should consider 

tagging infants as soon as they are moved into an open crib. For details about 

electronic tagging systems see 3-3-5 beginning on page 21.

Pediatric Units

Pediatric units also offer special challenges when trying to safeguard children from

nonfamily abduction. While 14 percent of the infants abducted from healthcare 

facilities are from nurseries, 14 percent of the infants abducted are from pediatric 

units including children’s hospitals. It is recommended that similar and consistent

security protocols be implemented in pediatric areas since they can also include 

infants. It is imperative that the facility’s assessment be used to identify any variations in security protocols for inpatient infant unit(s) to demonstrate reasonable 

and appropriate protection processes for pediatric patients.

As in special-care-nursery situations, parents may not be constantly present 

until the child’s discharge. The constant presence of family should be encouraged for those patients younger than 12 months. In addition nurses may not be 

ever-present in the baby’s room when family is absent, and infants are not usually

placed in a centralized nursery when family members are absent. Pediatric units 

in a community-based hospital may be mixed with adults or on a multiservice unit

with a pediatric population. Thus pediatric units often are less secure or “hardened”

than maternal-child-care units and special-care nurseries, and special considerations 

are needed when employing items as noted in 3-4-1 beginning on page 24.

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For instance if an electronic tagging system is to be used with patients in the 

pediatric unit, allowances need to be made for those patients who are permitted

to leave the unit such as alarm activation once the child has been gone a specified

period of time. When Code Pink is used in a facility to alert staff members that there

is a missing infant, consider using a different code word, or the same code word

with an age descriptor, for missing pediatric patients and older children visiting the 

facility. It is important for staff members to clearly understand the type of missing

patient/child they are looking for from an infant being carried when a Code Pink

is called to an older more ambulatory pediatric patient/visitor.

While nonfamily infant abductions grab the headlines, more common are family abductions involving custody disputes, child abuse, and Department of Family 

and Children Services (DFCS) intervention. While this problem is widespread and 

statistical information is available about the subject of family abduction, there is little

systematic data available about such abductions from healthcare facilities. It is likely, 

however, that family abductions and DFCS intervention are grossly underreported. 

And, because these cases often involve abuse and/or neglect issues, the child may

be at greater risk than newborn infants taken from maternal-child-care units.

Upon admission of a child to a patient room and during the orientation process, 

nursing staff members should ask the parent/guardian if there is any personal

circumstance the facility should be aware of, especially as it relates to a family situation that might place the parent/guardian or child at risk. Special concern should

be placed on single persons who may be involved in a custody dispute or if the 

mother has a protective order against the baby’s father. This line of questioning is

best accomplished with a caring attitude because parents/guardians will often open

up about past problems of abuse and even attempted abductions by the noncustodial

parent in such situations.

Several factors to review when considering to establish “protection” for a 

patient include abduction risk, age of child, probability for violence, circumstances 

surrounding the risk, visitor-screening program, and coordination of security concerns with state and local agencies responsible for taking custody of children due 

to abuse and/or neglect. Protection strategies include

n	 “Red flagging” the child’s name in the system to indicate no information is to

be released

n	 Admitting the child under an assumed name

n Placing the child in an isolation room or the intensive-care unit

n	 Placing an assumed name on the child’s door

n	 Using a wireless CCTV camera with a monitor at the nurses’ station to closely

watch the child

n	 Increasing frequency of observation in the patient’s area

n Posting a description of the potential abductor with security, nursing, and the 

front desk or reception area

n	 Posting a security officer at the patient’s room/floor/unit

Please use the self-assessment tool, beginning on page 59, when assessing needs 

in Pediatric Units.
48 - For Healthcare Professionals

Outpatient Areas

Clinics or postpartum-treatment facilities for mothers, pediatric clinics, healthmaintenance organizations (HMO), and waiting rooms in healthcare facilities 

should clearly post a policy stating parents or guardians are not allowed to leave children 

unattended in the waiting room or delegate that duty to others. Such facilities should 

enforce this rule by reminding parents when they violate it. Post this policy in all 

the languages spoken by patients in your service area.

	 Facilities need to establish a policy regarding the specific identification worn

by staff members authorized to transport and treat the infant, and inform parents/

guardians of that policy. In addition, when possible, avoid having outpatient services 

located in or near inpatient service areas to cut down on the number of visitors to 

in-service areas where infants stay while in the facility.

Visiting nurses, home-health aides, home-health-care workers, HMO workers, nurses in physicians’ offices, and all nursing and medical students should be

issued the same unique photo ID “to transport” badge referenced in Guidelines 

3-2-4 and 3-2-5 beginning on page 15 and 3-2-14 beginning on page 19. Whenever 

possible, families should be notified of planned visits to their home, and families should be 

cautioned against allowing anyone to enter their home who does not have the approved 

form of identification issued by that service.

The proliferation of identity-theft crimes demonstrates that fraudulent identification is readily made and easily obtained. As such patients need to be reminded 

they should always ask to see the visiting home nurse’s photo ID, as issued by the

appropriate facility, association, affiliation, and/or employer, and contact that

issuing entity for verification. To facilitate this process, upon discharge, the facility

should provide the parents with a list of telephone numbers parents may use to 

verify/confirm the identity of the visiting home nurse.

	 The visiting nurses and nursing/medical students should be included underthe

issuing facility’s policies and procedures and critical-incident-response plan. All

other healthcare workers need to be included under a critical-incident-response 

plan from their employer whether a physician, HMO, government agency, or other 

entity. Care must be taken to encourage physicians who are in direct contact with 

infants to fulfill this requirement.

Homes

As stated previously, as of the publication of this book in January 2009, there has 

been no use of violence against mothers within healthcare facilities, and, of the 99 

infant abductions from homes, 29 percent involved some form of violent act committed against the mother including homicide. Clearly the location of abduction

in the last few years is moving primarily to the home; therefore, the importance 

of patient education before postpartum discharge is paramount. Consider using 

a signed release form indicating the parent has received the information titled 

“What Parents Need to Know” beginning on page 51. There have been several 
For Healthcare Professionals - 49

cases where an abductor has made initial contact with a mother and infant in the 

healthcare setting and then subsequently abducted the infant from the family home.

Ahigh degree of diligence should, therefore, be exercised by the healthcare facility

when releasing information about the birth of the infant. It is inappropriate for the 

healthcare facility to supply birth announcements to the press containing a family’s

complete home address or any other unique identifying data.

	 An important difference is evident in the abduction style and technique used in

healthcare versus nonhealthcare-setting abductions. Since the use of violence is more

prevalentin home settings,families shouldbe cautionedto allow only family members

and known friends into the home, not merely acquaintances met during the mother’s

pregnancy and/orrecent stay in the birthing/healthcare facility or known only online

such as in social networking sites, chatrooms, and forums. See “What Parents Need 

to Know” beginning on page 51 and the 1995 listing for Analysis of Infant Abductions

by Ann Burgess and Kenneth Lanning in the “Bibliography” on page 80.

Additionally, with the trend toward reduced stays in facilities for mothers once 

they have given birth (see “Bibliography” on page 82 for the 2002 entry by Madden, 

et al., of their article in The New England Journal of Medicine), a reduced stay for a 

mother increases her recovery at home during a critical time when she needs to be 

vigilant about her infant’s physical safety. Thus there could be an even greater

increase in the infant’s risk of being abducted from the home setting because typically

fewer people are in the home to help the mother with line-of-sight supervision. As 

a result every effort should be made to have trusted family members and friends

assist mom in the home with all child-care duties until she is fully recovered and 

able to take those over herself.

The most extreme cases of infant abduction from homes and other places outside

of the healthcare setting involve a victim mother who is pregnant and her unborn

child is cut from her womb by the abductor. NCMEC has documented 11 such 

cases from July 1987 through July 2008. Tragically, during that time period, 10 of 

these mothers and 3 of these infants died from their injuries. Miraculously 8 of the

infants victimized in this way survived their traumatic abductions.

The profile of a typical abductor holds true in these extreme cases of infant abduction.

Healthcare providers must reinforce patient education regarding personal-safety 

issues in relation to this rare and extreme type of infant abduction.

Case

Example While her husband was at work a young mother of 2 sons took some time for 

herself and worked out while their infant son, a 1-month old, napped and his 

older brother, a 4-year-old, played in another room.

Just before 10:00 a.m., the 4-year-old noticed 2 adults peering in the front windows 

of the home. He did not answer the door and returned to playing as he thought 

they had left. Instead the pair apparently entered the home through an unlocked 

garage door.
50 - For Healthcare Professionals

The 4-year-old observed the pair taking his younger brother and tried to alert 

his mother. By the time his mother reached the room where the infant had been 

napping, the pair had left the home with the infant and were observed driving away.

Law enforcement was called, and by 10:30 a.m. a statewide AMBER Alert had been 

issued based on the detailed description provided by the 4-year-old including the 

fact that the woman was wearing a form of photo ID. Within 5 hours, in response 

to a lead generated by the AMBER Alert, the infant was located about 100 miles 

away, and the female suspect was taken into custody.

While interviewing the victim family, investigators learned that one month earlier, 

prior to discharge from the hospital, the victim parents were approached by a 

woman claiming to be the visiting home nurse assigned to them. The parents 

indicated the woman appeared to be legitimate and was wearing a form of photo 

ID when she met with them. This woman did go to their home a few weeks later 

to check on the infant. The description of the “visiting nurse” was similar to that 

of the woman who took the baby from the home.

Key Factors Helping to Recover the Infant

Key factors that helped in recovering this infant included the

 Immediate response by law enforcement and speed with which they issued 

the AMBER Alert

 Amount of descriptive information about the suspects as provided by the 

4-year-old

 Response of the public to the AMBER Alert

Teaching Point

Facilities need to take every opportunity to educate parents about any follow-up 

care in the home offered by the facility after discharge and the procedures surrounding that care. Such should include consideration of providing this information 

to the patient on the discharge instruction sheet he or she signs with the patient 

keeping a copy of the discharge sheet when leaving the facility. See 3-2-14 beginning on page 19 for additional information regarding this point.
For Healthcare Professionals - 51

6. What Parents Need to Know

Personnel in healthcare facilities and at prenatal visits should remind parents, in 

a warm and comforting way, of the measures they should take to provide maximum child protection. The guidelines listed below provide good, sound parenting 

techniques that can also help prevent abduction of infants while in the healthcare 

facility where the baby was born and once the parents take the baby home. They 

should be shared with expectant parents at prenatal visits, during the tour of the

facility pre-delivery, and during the parents stay at the time of birth.

Please note in many cases of infant abduction, the abductor was bilingual while 

the victim mother was not. Healthcare facilities need to provide multilingualeducational information to these parents because infants’ risk levels of abduction

are substantially elevated when parents are not properly educated in their native 

language about the safety issues involved. See page 54 for the Spanish-language 

version of these prevention tips, and healthcare facilities should consider translating these tips into any other languages used by patients in their service area.

FACILITY 1. At some point before the birth of your baby, investigate

security procedures at the facility where you plan to

give birth to your baby and request a copy of the facility’s written guidelines about procedures for “special

care” and security procedures in the maternity ward. 

Know all of the facility’s procedures in place to safeguard your infant while staying in that facility.

FACILITY	 2.	 While it is normal for new parents to be anxious, being

deliberately watchful over the newborn infant is of 

paramount importance.

FACILITY 3. Never leave your infant out of your direct, line-of-sight 

even when you go to the restroom or take a nap. If you 

leave the room or plan to go to sleep, alert the nurses 

to take the infant back to the nursery or have a family member watch the baby. When possible, keep the 

infant’s bassinet on the side of your bed away from the

door(s) leading out of the room.

FACILITY	 4.	 After admission to the facility, ask about the facility’s

protocols concerning the routine nursery procedures, 

feeding and visitation hours, and security measures. 

Do not hesitate to politely ask direct questions and 

settle for nothing less than an acceptable explanation.

FACILITY 5. Do not give your infant to anyone without properly 

verified identification as issued by that facility. Find

out what additional or special identification is being
52 - For Healthcare Professionals

worn to further identify facility personnel who have 

authority to transport your infant. Speak to a person 

in authority (e.g., unit director, charge nurse) if you 

have any questions or concerns. Be sure everyone who 

is helping you watch your infant while you are in the 

facility understands these safeguards and does not 

release your infant to any unauthorized person.

FACILITY	 6.	 Become familiar with the staff members who work in the

maternity unit. During short stays in the facility, ask to be 

introduced to the nurse assigned to you and your infant.

FACILITY 7. Question unfamiliar persons entering your room or 

inquiring about your infant — even if they are in the 

facility’s attire or seem to have a reason for being there.

Immediately alert the nurses’ station.

FACILITY 8. Determine where your infant will be when taken for 

tests, and how long the tests will take. Find out who has 

authorized the tests. If you are uncomfortable with anyone who requests to take your infant or unable to clarify 

what testing is being done or why your infant is being 

taken from your room, it is appropriate to go with your 

infant to observe the procedure. Or if you are unable to 

accompany your infant, have a family member go along.

FACILITY 9. For your records to take home, have at least one color 

photograph of your infant (full, front-face view) taken along 

with footprints and compile a complete written description of your infant including hair and eye color, length, 

weight, date of birth, and specific physical characteristics.

FACILITY/HOME	 10.	 At some point after the birth of your baby, but before

discharge from the facility, request a set of written

guidelines about the procedures for any follow-up care 

extended by the facility that will be scheduled to take

place in your home. Do not allow anyone into your 

home who says he or she is affiliated with the facility

without properly verified identification as issued by

that facility. Find out what additional or special identification is being worn to further identify those staff

members who have authority to enter your home.

FACILITY/HOME	 11.	 Consider the risk you may be taking when permitting

your infant’s birth announcement to be published in

the newspaper or online. Birth announcements should 

never include the family’s home address and be limited
For Healthcare Professionals - 53

to the parents’ surname(s). In general, birth announcements in newspapers are not endorsed by most experts.

 Use caution in creating websites for your infant or posting photographs of your infant on websites. When doing 

so limit access to those you know personally and trust. 

To limit anyone else’s potential misuse of a photograph

of your infant, carefully consider anyone’s request to take

a picture of your infant and only share photographs of 

your infant with those you know personally and trust.

HOME 12. The use of outdoor announcements such as signs, balloons, large floral wreaths, and other lawn ornaments 

are not recommended to announce a birth because they 

call attention to the presence of a new infant in the home.

HOME 13. Only allow persons into your home who are wellknown by the mother. It is ill advised to allow anyone 

into your home who is just a mere or recent acquaintance or known only online such as in social-networking 

websites, chatrooms, and forums, especially if met 

briefly since you became pregnant or gave birth to 

your infant. There have been several cases where an 

abductor has made initial contact with a mother and 

infant in the healthcare-facility setting and then subsequently abducted the infant from the family home. If 

anyone should arrive at the home claiming to be affiliated with the healthcare facility where the infant was 

born or other healthcare provider, remember to follow 

the procedures outlined in number 10 above. A high 

degree of diligence should be exercised by family members when home with the infant. The bottom line is, the

infant’s family is the domestic security team, and all family 

members should be sensitive to any suspicious visitors.

PUBLIC PLACES 14. If you must take your infant out, whenever possible, 

take a trusted friend or family member with you as an 

extra set of hands and eyes to protect and constantly

observe the infant. Never leave a child alone in a 

motor vehicle. Always take the child with you. Never 

let someone you don’t know pick up or hold your

child. There have been cases in which initial contact 

with a mother and infant was made in other settings

such as shopping malls or bus stations.

Note The National Center for Missing & Exploited Children encourages the distribution of the 

English- and Spanish-language versions of “What Parents Need to Know” by healthcare facilities to patients who will be giving birth to infants in their facility. To obtain 

these guidelines and NCMEC’s Reprint Policy, please call NCMEC at 1-800-THE-LOST®

(1-800-843-5678) or visit www.missingkids.com.
54 - For Healthcare Professionals

Proteja el futuro de su bebé

Medidas para prevenir el secuestro de bebés

Lo que los padres necesitan saber

El personal de los hospitales o centros de salud y en las visitas prenatales debe 

recordarles a los padres, de una manera amable y reconfortante, las medidas que 

deben tomar para proveerla máxima seguridad a su bebé. Las medidas enumeradas

a continuación son técnicas que también pueden ayudar a los padres a prevenir

el secuestro del bebé del centro hospitalario donde nació o de su propio hogar.

Deberían ser explicadas a los futuros padres durante las visitas prenatales, durante

la visita a las instalaciones antes del parto y durante la permanencia de los padres 

en el momento del nacimiento.

Debe tenerse en cuenta que en muchos casos de robo de infantes el secuestrador 

o la secuestradora era bilingüe mientras que la madre de la víctima no lo era. Es 

necesario que los centros de salud provean información educativa multilingüe a 

estos padres porque los niveles de riesgo de secuestro del infante aumentan 

sustancialmente cuando no se educa adecuadamente a los padres en su idioma 

nativo sobre las cuestiones de seguridad involucradas.

CENTRO

HOSPITALARIO 1. Antes del nacimiento de su bebé debe investigarlos

procedimientos de seguridad del establecimiento 

donde piensa dar a luz y pedir una copia de 

los procedimientos de “cuidado especial” y de 

seguridad de la sala de maternidad del hospital. 

Conozca todos los procedimientos que se han 

adoptado para proteger a su bebé mientras esté

en el establecimiento.

CENTRO

HOSPITALARIO 2. Aunque es normal que los padres se sientan 

ansiosos, es muy importante vigilar activamente 

a su bebé.

CENTRO

HOSPITALARIO	 	 3.	 Nunca deje a su bebé fuera de su vista, incluso

cuando vaya al baño o tome una siesta. Si sale 

de la habitación o tiene intenciones de dormir, 

avise a las enfermeras para que lleven a su bebé

a la sala de recién nacidos o pida a un miembro

de su familia que lo vigile. Siempre que sea 

posible mantenga la cuna del infante en el lado 

de su cama que está más alejado de la

puerta de la habitación.
For Healthcare Professionals - 55

CENTRO

HOSPITALARIO	 4.	 Después de entrar al hospital, infórmese sobre

los protocolos de rutina del establecimiento, las 

horas de comidas y de visitas y las medidas de 

seguridad. No tenga miedo de hacer preguntas 

directas de una manera cortés y no acepte otra

cosa que una explicación satisfactoria.

CENTRO

HOSPITALARIO	 5.		 No entregue su bebé a nadie que no tenga 

identificación del hospital debidamente

verificada. Averigüe cual es la identificación

adicional o especial del personal autorizado 

del hospital para transportar a su bebé. Si tiene

preguntas o alguna preocupación hable con 

una persona de autoridad (por ejemplo, el

director de la unidad o la enfermera encargada). 

Asegúrese de que todos los que la ayudan a 

vigilar su bebé mientras se encuentra en el

establecimiento comprenden estas salvaguardas 

y no le entregan su bebé a una persona que no

esté autorizada.

CENTRO

HOSPITALARIO	 	 	6.	 Conozca al personal que trabaja en la sala de

maternidad. Durante estancias breves en el 

hospital o centro de salud pida que le presenten 

a la enfermera encargada de usted y de su bebé

en cada turno.

CENTRO

HOSPITALARIO 7. Interrogue a las personas desconocidas que entren 

a su habitación o que pregunten sobre su bebé,

aunque estén vestidos con uniformes médicos del

hospital o parezcan tener alguna razón para estar 

allí. Avise de inmediato a las enfermeras.

CENTRO

HOSPITALARIO	 	 8.	 Averigüe donde estará su bebé cuando lo lleven

a hacerle exámenes, y cuánto tiempo durarán

dichos exámenes. Averigüe quién ha autorizado

los exámenes. Si no se siente cómoda con alguna

persona que quiera llevarse a su infante o si no 

puede averiguar qué exámenes quieren hacerle o

por qué quieren sacarlo de su habitación, acompañe

a su bebé para observar el procedimiento. O si

usted no puede acompañar al infante haga que 

lo acompañe un miembro de su familia.
56 - For Healthcare Professionals

CENTRO

HOSPITALARIO 9. Para los archivos que llevará a su casa, tome 

por lo menos una fotografía en colores de su 

bebé (de frente), junto con impresiones de la

planta del pie y escriba una descripción completa 

que incluya el color del cabello y de los ojos,

tamaño, peso, fecha de nacimiento y las 

características físicas especiales.

CENTRO

HOSPITALARIO/CASA	 10.	 Después del nacimiento de su bebé, pero antes

de salir del hospital, pida una copia escrita de 

los procedimientos para cualquier tratamiento 

de seguimiento que vaya a recibir en su casa. 

No permita entrar a su casa a ninguna persona 

que diga trabajar para el hospital sin verificar

debidamente que su documento de identificación

haya sido emitido por ese centro de salud. 

Averigüe cuál es la identificación adicional 

o especial del personal del hospital que tiene 

autorización para entrar a su casa.

CENTRO

HOSPITALARIO/CASA	 11.	 Considere el riesgo que corre al permitir la

publicación del anuncio del nacimiento de su 

bebé en el periódico o en línea. Los anuncios de

nacimientos nunca deben incluir el domicilio 

de la familia y deberían limitarse a los apellidos 

de los padres. En general, los expertos no

recomiendan anuncios de nacimiento en 

los periódicos.

Use cautela al crear sitios web para su bebé o al

colocar fotos de su bebé en sitios web. Al hacerlo,

limite el acceso sólo a personas a quienes 

conozca y en quienes tenga confianza. Para

limitar el mal uso potencial de una fotografía 

de su bebé por alguien, considere cuidadosamente

el pedido de toda persona que quiera tomar una 

foto del bebé y sólo comparta fotos de su bebé

con personas a quienes conozca personalmente 

y en las que tenga confianza.

CASA 12. No se recomienda el uso de decoraciones en 

la parte de afuera de su casa para anunciar el 

nacimiento de su bebé, por ejemplo carteles,
For Healthcare Professionals - 57

globos, coronas de flores y otros adornos de

jardín debido a que llaman la atención sobre la

presencia de un nuevo infante en la casa.

CASA	 13.	 Deje entrar a su casa sólo a personas a quienes

conozca bien. No debe dejar entrar a nadie que

acaba de conocer o a quién conoció sólo en

línea como en sitios de redes sociales, salas de 

chateo o foros, especialmente si conoció a esa 

persona brevemente desde que estuvo embarazada 

o desde que dio a luz. Hubo varios casos en 

los que el secuestrador hizo contacto inicial 

con la madre y con el infante en el hospital y 

luego secuestró al bebé de su hogar. Si alguien

se presenta al hogar diciendo estar afiliado al

hospital donde nació el bebé u otro centro de

salud, siga los procedimientos que se indican 

en el punto No. 10. Los miembros de la familia 

deben ser muy cuidadosos cuando se encuentran 

en el hogar con el infante. Es esencial recordar 

que la familia del infante es el equipo de 

seguridad en el hogar y todos los miembros 

de la familia deberían estar atentos a cualquier 

visitante sospechoso.

LUGARES PÚBLICOS 14. Si usted tiene que llevar a su infante a algún 

lado, cuando quiera que sea posible hágase 

acompañar por un amigo o un miembro de la 

familia para tener un par extra de manos y de

ojos para protegerlo y observarlo constantemente.

Nunca deje a un niño solo en un vehículo

automotor. Siempre lleve al niño o a la niña con 

usted. Nunca permita que una persona a quien 

usted no conozca alce o sostenga a su bebé.

Hubo casos en los cuales el contacto inicial 

con la madre y con el infante se hizo en otros 

lugares, como centros o galerías comerciales o 

estaciones de autobús.

Nota El Centro Nacional para Menores Desaparecidos y Explotados fomenta que los hospitales 

o centros de salud distribuyan las versiones en inglés y español de “Lo que los padres 

necesitan saber” a las pacientes que darán a luz en sus instalaciones. Para obtener estas 

pautas y la Política de Reimpresión del NCMEC llame al NCMEC al 1-800-THE-LOST®

(1-800-843-5678) o visite www.missingkids.com.
58 - For Healthcare Professionals
For Healthcare Professionals - 59

7. Self-Assessment for Healthcare Facilities

Self-assessment guides are helpful tools for recommendable/advisable policies and/or 

protocols. Consider using a multidisciplinary task force to complete this self-assessment 

tool on an annual basis. Use the complete assessment to document areas of compliance, 

to develop new protocols, and as an outline to revise/write policies and procedures 

based on these national guidelines. Remember a reorganization of staff members or 

staff assignments or remodeling of a facility will require immediate reassessment of 

these policies and protocols to help ensure all measures are still adequate.

3-1 General

3-1-1 Immediately report Essential

to the nurse manager/

supervisor, security, and

administration persons

exhibiting behaviors of

potential abductor.

Positively identify suspect. Essential

Interview suspect. Essential

3-1-2 Preserve report and Essential

interview records about

incident, many suggest from

a minimum of seven years up

to the child reaching adulthood.

3-1-3 Alert other birthing Essential

facilities in the area

of attempted abductions/

when person identified

who demonstrates

behaviors of

potential abductor.

3-1-4 For all attempted abductions

Notify law enforcement. Essential

Notify NCMEC. Essential

GUIDELINE STATUS

(Essential/

Recommended)

FACILITY

COMPLIES

(Yes/No)

COMMENTS
3-2 Proactive Measures

3-2-1 Develop, annually test, Essential

and annually critique

written proactiveprevention plan.

3-2-2 Immediately after Essential

birth of infant, attach

identically numbered

ID bands to infant,

mother, father/

significant other.

The infant’s band needs Essential

to be examined and verified

with the mother’s band when

taking the infant for care as

well as upon delivery of the

infant to the mother after

care has been rendered.

No matter what form of Essential

attachment bands or clamps

are used with the electronic

tagging of infants, assure no

delay in activation of alarm

function upon separation

of the tag from the infant.

Frequent, ongoing testing Essential

of the system is needed.

Staff members should be Essential

trained to immediately

respond so there

is no delay between

detection of the alarm

condition and generation

of the alarm notification.

Staff members should Essential

never consider an alarm

to be a “false alarm.”

60 - For Healthcare Professionals

GUIDELINE STATUS

(Essential/

Recommended)

FACILITY

COMPLIES

(Yes/No)

COMMENTS
For Healthcare Professionals - 61

3-2-3 Prior to removal of newborn

from birthing room or

within a maximum of

two hours of the birth

Footprint infant. Essential

Take color photograph/ Essential

video/digital image of infant.

Perform and record full, Essential

physical assessment

and description of infant.

Note all these items in Essential

infant’s medical chart.

Store sample of infant’s cord Essential

blood and any other blood

specimens until at least

day after infant’s discharge.

Place electronic security tag, Recommended

if used by facility.

3-2-4 Require all healthcare Essential

personnel to wear, abovethe-waist, up-to-date,

conspicuous, colorphoto ID badges.

3-2-5 Personnel allowed to Essential

transport infants should

wear a unique identification

such as a distinctive and

prominent color or marking

to designate personnel

authorized to transport

infants that is clearly

different than the general

healthcare ID badge.

GUIDELINE STATUS

(Essential/

Recommended)

FACILITY

COMPLIES

(Yes/No)

COMMENTS
62 - For Healthcare Professionals

3-2-6 While infants are transported

within the healthcare facility,

see that

Only authorized staff members Essential

and the mother/father/

significant other with identically

numbered ID band to that

of the infant’s are allowed

to transport that infant.

Educate mother/father/ Essential

significant other about the

importance of this precaution.

An infant is never left Essential

without direct, line-ofsight supervision.

Infants are taken to mothers Essential

one at a time.

Infants are always pushed Essential

in a bassinet and never

carried in anyone’s arms.

Require family members Essential

transporting the infant outside

of the mother’s room, including

mother, father, significant other,

to wear an ID wristband

matching that of the infant’s

ID wristband.

3-2-7 Distribute guidelines, for Essential

parents in preventing infant

abductions, during prenatal

visits, in childbirth classes,

on pre-admissions tours, upon

admission, at postpartum

instruction, and upon discharge.

GUIDELINE STATUS

(Essential/

Recommended)

FACILITY

COMPLIES

(Yes/No)

COMMENTS
For Healthcare Professionals - 63

Upon admission consider Recommended

having the patient sign a

document noting receipt

of these guidelines with

the patient retaining the

guidelines and a copy of

the signed document.

3-2-8 Train staff members, at Essential

all levels, on protecting

infants from abduction.

3-2-9 Always place infants Essential

in direct, line-ofsight supervision.

3-2-10 Do not post mother’s Essential

or infant’s full name

where it will be visible

to visitors especially

on items such as

bassinet cards or

white boards.

3-2-11 Establish an access- Essential

control policy for the

nursing unit, nursery,

maternity, neonatalintensive care,

and pediatrics.

At the front lobby Recommended

or entrance to those

units, instruct healthcarefacility personnel to ask

visitors which mother

they are visiting.

3-2-12 Require a show of the Essential

ID wristband for the

person taking the

infant home from the

GUIDELINE STATUS

(Essential/

Recommended)

FACILITY

COMPLIES

(Yes/No)

COMMENTS
64 - For Healthcare Professionals

healthcare facility and

be sure to match the

number on the infant’s

band, as worn on the

wrist and ankle, with

number on the band

worn by the mother/

father/significant other.

3-2-13 No home address or Essential

other unique information

should be divulged

to the public in birth

announcements that

would put the infant

and family at risk

after discharge.

3-2-14 When providing home Essential

visitation services,

personnel entering

patients’ homes need

to wear an authorized

and unique form

of identification

strictly controlled

by the issuing

organization and

explained to parents

at the time of discharge.

Consider providing this Recommended

information in the discharge

instruction sheet the patient

signs and takes home.

3-3 Physical-Security Safeguards

3-3-1 Develop written Essential

assessment of

risk potential

for infant abduction.

GUIDELINE STATUS

(Essential/

Recommended)

FACILITY

COMPLIES

(Yes/No)

COMMENTS
For Healthcare Professionals - 65

Conduct written assess- Essential

ment on a yearly basis or

more often as targets, risks,

and methods change such

as new construction.

3-3-2 Install alarms on all Essential

stairwell and exit doors

on the perimeter of

the maternity, nursery,

neonatal-intensive-care,

and pediatrics units.

Respond to all alarms and Essential

instruct responsible staff

members to silence and reset

an activated alarm only

after direct observation

of the stairwell or exit

and person using it.

When an alarm is activated Recommended

properly document it,

submit documentation

to proper facility authority,

and generate monthly

reports to be reviewed

with security and nursing.

3-3-3 All doors to all nurseries must Essential

have self-closing hardware,

remain locked at all times,

and a staff member should

be present at all times when

the nursery is in use.

3-3-4 All doors to lounges, Essential

locker rooms, and

storage areas where

staff members change/

leave clothing or scrub

suits must be under

GUIDELINE STATUS

(Essential/

Recommended)

FACILITY

COMPLIES

(Yes/No)

COMMENTS
66 - For Healthcare Professionals

strict access control

at all times.

3-3-5 Conduct and document Essential

a needs assessment

for an electronic-articlesurveillance (EAS)

detection system

using an EAS infantbracelet tag that is

always activated and

tied to video recording

of the incident/

alarm activation

and integrated with

electronic locking devices

to prevent exiting when

a tagged infant is in close

proximity to the exit.

When using an Essential

electronic tagging

system, document all

legitimate activations.

When using an Recommended

electronic tagging

system, test it

weekly, in each

individually protected

area/at each door,

by way of using

a randomly selected

tag (not a test tag).

Monthly testing and Essential

documentation of

these monthly tests

is essential.

Report test results to Recommended

nurse manager, security

GUIDELINE STATUS

(Essential/

Recommended)

FACILITY

COMPLIES

(Yes/No)

COMMENTS
For Healthcare Professionals - 67

manager, and proper

authority within facility.

When using the system Recommended

in pediatric units with

patients who are permitted

to leave the unit, allow

for alarm activation after

a specified period of time.

3-3-6 Install and properly Essential

maintain a securitycamera system.

3-3-7 Position camera so Essential

it will fully capture the

face of all persons using

any public entrances,

including elevators, to

the infant/pediatrics units.

3-3-8 Install signage in the Recommended

maternal-child-care

unit; lobbies; obstetric,

emergency room, and

day-surgery waiting areas

instructing visitors not

to leave their children

out of their line-of-sight.

3-3-9 Consider electronic Recommended

surveillance and accesscontrol equipment that

includes color cameras with

video/digital recording, alarms

on all stairwell and exit

doors on the perimeter

of the unit, testing

and maintenance

of that equipment

per manufacturer’s

recommendations,

GUIDELINE STATUS

(Essential/

Recommended)

FACILITY

COMPLIES

(Yes/No)

COMMENTS
68 - For Healthcare Professionals

and retention of tapes/

digital recordings for

at least seven days.

3-4 Critical-Incident-Response Plan

General

3-4-1 Develop written, critical- Essential

incident-response plan

in the event of an

infant abduction.

Conduct full-house Essential

response drill at

least annually.

Conduct quarterly Recommended

unit-specific drills,

“tabletop” exercises,

or audit-type exercises.

3-4-2 Call NCMEC at Essential

1-800-THE-LOST®

(1-800-843-5678)

for advice and

technical assistance.

Nursing

3-4-3 Immediately search the Essential

entire unit.

3-4-4 Immediately and Essential

simultaneously

call facility

security

and/or other

designated authority.

3-4-5 Secure and protect the Essential

crime scene, and allow

no entrance until law

enforcement releases it.

GUIDELINE STATUS

(Essential/

Recommended)

FACILITY

COMPLIES

(Yes/No)

COMMENTS
For Healthcare Professionals - 69

3-4-6 Move the parents of the Recommended

abducted infant, but not

their belongings, to a

private room off the

maternity floor.

Have the nurse assigned Recommended

to the mother and infant

continue to accompany

the parents at all times.

Coordinate services Recommended

to meet the emotional,

social, and spiritual

needs of the family.

Provide regular, ongoing, Recommended

information updates to

the family in collaboration

with other entities such

as law enforcement.

Secure all records/charts Recommended

of the mother and infant.

Notify lab and place Recommended

STAT hold on infant’s

cord blood and any other

blood specimens.

Designate a room for Recommended

other family members

to wait in giving them

easy access to any

updates in the case

while offering the

parents some privacy.

Designate a room for Recommended

media and another one

for law enforcement.

GUIDELINE STATUS

(Essential/

Recommended)

FACILITY

COMPLIES

(Yes/No)

COMMENTS
70 - For Healthcare Professionals

3-4-7 Nurse manager/supervisor Recommended

brief all staff members of

the unit.

Nurses should then Recommended

explain the situation

to each obstetric

patient/mother while

the mother and her

infant are together.

3-4-8 Assign one staff person Recommended

to be the primary liaison

between the parents and

facility after the discharge

of the mother from

the facility.

3-4-9 Hold a group discussion Essential

session as soon as

possible in which all

personnel affected

by the abduction are

required to attend.

Security Personnel

3-4-10 Immediately and Essential

simultaneously respond

to perimeter points of

the grounds to observe

persons leaving, and

record vehicle licenseplate numbers.

Call local law enforcement, Essential

and make a report.

Then call the local Essential

FBI office requesting

assistance from

GUIDELINE STATUS

(Essential/

Recommended)

FACILITY

COMPLIES

(Yes/No)

COMMENTS
For Healthcare Professionals - 71

the squad handling

crimes committed

against children.

After securing the perimeter, Essential

proceed to the location of

the incident and activate a

search of the entire healthcare

facility, interior and exterior.

Assume control of the Essential

crime scene until law

enforcement arrives.

Assist nursing staff Essential

members in establishing

and maintaining security

in the unit.

Notify public relations. Essential

Secure videotapes/ Essential

digital recordings for

seven days prior to the

date of the incident, and

request the same from other

healthcare facilities in the

area and adjacent businesses.

3-4-11 Facility’s media plan Essential

should mandate

all information about

the abduction be cleared

by facility and lawenforcement authorities

involved before being

released to staff members

and the media.

3-4-12 Brief the healthcare-facility Essential

spokesperson who can

GUIDELINE STATUS

(Essential/

Recommended)

FACILITY

COMPLIES

(Yes/No)

COMMENTS
72 - For Healthcare Professionals

inform and involve local

media by requesting their

assistance in accurately

reporting the facts of the

case and soliciting the

support of the public.

3-4-13 Call NCMEC at Essential

1-800-THE-LOST

(1-800-843-5678)

for technical assistance

in handling ongoing

crisis management.

3-4-14 Notify newborn nurseries, Essential

pediatric units, emergency

rooms, outpatient

clinics for postpartum/

pediatric care at other

local healthcare facilities,

and the health department’s

bureau of vital statistics

about the incident, and

provide a full description

of the infant and suspected

or alleged abductor.

3-4-15 Document specific review Recommended

of facility’s infant-security

and safety program.

Law Enforcement

3-4-16 Enter the infant’s name Essential

and description in the

FBI’s National Crime

Information Center’s

Missing Person File

(NCIC-MPF).

3-4-17 Call NCMEC at Essential

1-800-THE-LOST

GUIDELINE STATUS

(Essential/

Recommended)

FACILITY

COMPLIES

(Yes/No)

COMMENTS
(1-800-843-5678)

to request technical

assistance, network

with other agencies

and organizations,

assist in obtaining

media coverage of

the abduction, and

coordinate dissemination

of the infant’s photograph.

3-4-18 Call the local FBI office Essential

requesting the assistance

of the Crimes Against

Children Coordinator

with technical and forensicresource coordination;

computerized-casemanagement support;

investigative, interview,

and interrogation strategies;

and information about

behavioral characteristics

of unknown offenders.

3-4-19 Immediately secure and Essential

review any available

videotapes/digital

recordings from the

abduction scene and

contact all other birthing

facilities in the community

and adjacent businesses

to request the retrieval

and secure storage of

the previous seven days’

worth of videotapes/digital

disks for review.

3-4-20 Set up one dedicated Recommended

local telephone hotline

for sightings/leads or

For Healthcare Professionals - 73

GUIDELINE STATUS

(Essential/

Recommended)

FACILITY

COMPLIES

(Yes/No)

COMMENTS
coordinate this function

with a local organization.

3-4-21 Polygraph infant’s parents, Recommended

female offender, and male

companion of offender.

3-4-22 Charge abductor. Essential

Make every effort to Essential

sustain a conviction.

3-4-23 Release of information Essential

concerning infant

abduction should

be well planned and

agreed upon by the

healthcare-facility

and law-enforcement

authorities involved.

Keep family fully informed. Essential

Public Relations

3-4-24 Provide facts of case to Essential

media and ask for their

assistance in releasing

information to the

public in hopes

of generating

leads about

the infant.

Limit information released Recommended

to that which is approved

by law enforcement and

healthcare facility, minimizes

information about security

procedures and technology

used within the facility, and

refrains from blaming victim

families for any aspect of

the abduction.

74 - For Healthcare Professionals

GUIDELINE STATUS

(Essential/

Recommended)

FACILITY

COMPLIES

(Yes/No)

COMMENTS
Place a news release about Recommended

the abduction on the

facility’s website.

3-4-25 Provide written Essential

statement to

address callers’

concerns over the

abduction, especially

for anxious parents who

are planning to deliver

their infants at that

facility, and instructions

about how to handle

tips or information about

the abduction.

3-4-26 Activate the crisis Essential

communication plan.

For Healthcare Professionals - 75

GUIDELINE STATUS

(Essential/

Recommended)

FACILITY

COMPLIES

(Yes/No)

COMMENTS
76 - For Healthcare Professionals
8. Bibliography

The partial bibliography below outlines, in chronological order, the benchmark 

articles in journals and publications for healthcare professionals about this issue. For

further information about related articles from popular magazines and newspapers, 

contact the National Center for Missing & Exploited Children’s Jimmy Ryce Law

Enforcement Training Center.

	 The specific date of foreseeability of a particular infant-abduction incident may

vary; however, there is wide agreement foreseeability affixed to healthcare nationwide by January 1992.

1965

Wierschem, Joseph. “Know Them By Their Feet.” Medical Record News: Journal of 

the American Association of Medical Record Librarians (June 1965), pp. 158-168.

1966

Gleason, Doris. “Tightening the Loopholes in Newborn Identification.” Hospitals: 

Journal of the American Hospital Association, Vol. 40 (August 1, 1966, Part I), pp. 60-63.

Anonymous. “Footprinting of Infants.” FBI Law Enforcement Bulletin (October 

1966), pp. 8-11.

1982

Colling, Russell L. Hospital Security. 2nd edition. Stoneham, Massachusetts: 

Butterworth-Heinemann, 1982.

1987

Johnston, Jeffrey. “Several Infants Kidnapped at Hospitals.” Family Practice News, 

Vol. 17, No. 18 (September 15-30, 1987), pp. 2, 53.

Johnston, Jeffrey. “Preventing Infants’Abduction From Hospital.” Ob. Gyn News, 

Vol. 22, No. 18 (September 15-30, 1987), pp. 3, 18.

1988

See Hospital Security and Safety Management, various articles from August 1988 

to present.

Rabun, John B., Jr., and Michelle P. Spring. “Newsbriefs: Infant Abductions.” 

Police: The Law Officer’s Magazine (December 1988), pp. 10-13.

1989

Rabun, John B., Jr. For Hospital Professionals. 1st edition. Alexandria, Virginia:

National Center for Missing & Exploited Children, May 1989.

For Healthcare Professionals - 77
Lloyd, David W. “Abduction of Infants From Hospitals: Issues of Risk Management.” Paper prepared as reference about topic, National Center for Missing & 

Exploited Children, October 1989.

Smock, Bruce K. “IAHSS Survey of Infant Abductions 1983-1989.” Journal of 

Healthcare Protection Management, Vol. 6, No. 1 (Fall 1989), pp. 40-50.

1990

Anonymous. “Maternity Unit Openness Brings Rise in Baby Kidnappings.” Hospital Risk Management, Vol. 12, No. 1 (January 1990), pp. 1-4.

Spadt, Susan Kellogg and Kenneth D. Sensenig, Sr. “Infant Kidnapping: It Can 

Happen in Any Hospital.” MCN: The American Journal of Maternity/Child Nursing, 

Vol. 15 (January/February 1990), pp. 52, 54.

Turner, James T. “Infant Abductions in Health Care: Critical Incident Response.” 

Journal of Police and Criminal Psychology (March 1990), pp. 2-10.

Anonymous. Newborn Nursery: Security Audit Instrument. Lombard, Illinois: Communicorp, 1990.

Fiesta, Janine. “Security: Whose Liability, Infant Kidnapping.” Nursing 

Management, Vol. 21, No. 5 (May 1990), pp. 16-17.

Eubanks, Paula. “Hospital Nursery Kidnappings Are Rare But Devastating.” 

Hospitals: The Magazine for Health Care Executives (June 20, 1990), pp. 64, 66.

Smock, Bruce K. “How to Prevent Abductions of Infants from Hospitals.” Health 

Facilities Management, Vol. 3, No. 7 (July 1990), pp. 18-24.

Anonymous. “Infant Kidnappings: Hospitals, Employees More Vigilant.” Healthwire Vol. 12, No. 6 (November/December 1990), p. 3.

1991

Rabun, John B., Jr. For Hospital Professionals. 2nd edition. Alexandria, Virginia:

National Center for Missing & Exploited Children, March 1991.

Safeguard Their Tomorrows is a program consisting of educational materials for 

healthcare professionals and distributed by Mead Johnson Nutrition. Nationwide 

distribution of this program began in June 1991.

Anonymous. “NAACOG Safeguards Future of Infants with New Video.” NAACOG 

Newsletter, Vol. 18, No. 8 (August 1991), p. 3.

78 - For Healthcare Professionals
Wilkie, Joy A. A Sense of Security: A Hospital Guide to Infant Security in the 

Maternity Unit. Columbus, Ohio: Ross Laboratories, 1991.

Anonymous. “Risk Analysis: Preventing Infant Abductions.” Hospital Risk Control

(September 1991), pp. 2-16.

Anonymous. “Infant Abductions from Hospitals.” Hospital Topics, Vol. 69, No. 4 

(Fall 1991), p. 43.

Westerbeck, Tim. “A Hospital’s Worst Nightmare.” Public Relations Journal

(November 1991), pp. 8, 12.

Rabun, John B., Jr. “Preventing Abduction of Infants from Hospitals.” Plant, Technology & Safety Management Series by The Joint Commission, No. 4 (1991 Series), 

pp. 7-13.

1992

Beachy, Patricia and Jane Deacon. “Preventing Neonatal Kidnapping.” JOGNN, 

Vol. 21, No. 1 (January/February 1992), pp. 12-16.

Dowdell, Elizabeth Burgess and John B. Rabun, Jr. “Newborn Infant Abductions 

From Hospitals.” Child Trauma I: Issues and Research. Ann Burgess, ed. New York 

& London: Garland Publishing, Inc., (1992), pp. 49-60.

Anonymous. Hospital Supervisor’s Bulletin. Waterford, Connecticut: Bureau of 

Business Practice, February 15, 1992.

LeCroy, Maura. “Should Birth Notices be Published?” Public Relations Journal

(March 1992), p. 8.

Rabun, John B., Jr. For Hospital Professionals. 2nd edition, revised. Alexandria,

Virginia: National Center for Missing & Exploited Children, March 1992.

Colling, Russell L. Hospital Security. 3rd edition. Stoneham, Massachusetts:

Butterworth-Heinemann, 1992.

Martin, Sam. “Taking Care of Baby.” SECURITY, Vol. 29, No. 5 (May 1992), p. 66.

Anonymous. “Birth Notices Link Hospitals to Infant Kidnapping, Liability.” Hospital Risk Management (August 1992), pp. 101-104.

Rabun, John B., Jr. “Guidelines on Preventing Abduction of Infants from the 

Hospital.” Journal of Healthcare Protection Management, Vol. 8, No. 2 (Summer 

1992), pp. 36-49.

For Healthcare Professionals - 79
Anonymous. “Infant Kidnapping.” Key Hospital Security Issues. Chicago, 

Illinois: American Hospital Association, 1992, pp. 17-19.

Beachy, Patricia. “Ask the Experts.” NAACOG Newsletter, Vol. 19, No. 11

(November 1992), p. 9.

1993

Yutzy, Sean; James K. Wolfson; and Phillip J. Resnick. “Child Stealing by 

Cesarean Section: A Psychiatric Case Report and Review of the Child Stealing 

Literature.” Journal of Forensic Sciences, Vol. 38, No. 1 (January 1993), pp. 192-196.

Butz, Arlene M.; Frank A. Oski; Jaque Repke; and Beryl J. Rosenstein. “Newborn 

Identification: Compliance with AAP Guidelines for Perinatal Care.” Clinical 

Pediatrics, (February 1993), pp. 111-113.

Anonymous. “AWHONN Nurse Thwarts Potential Infant Abduction.” 

AWHONN Voice, Vol. 1, No. 4 (April 1993), pp. 1, 3.

1994

Stapleton, Michael E. “Infant Footprints.” FBI Law Enforcement Bulletin, Vol. 63, 

No. 11 (November 1994), pp. 14-17.

Rabun, John B., Jr., and Janet Lincoln. “Preventing Infant Abductions from Health 

Care Facilities.” NANN’s Neonatal Network, Vol. 13, No. 8 (December 1994), pp. 61-63.

1995

Burgess, Ann Wolbert and Kenneth V. Lanning. An Analysis of Infant Abductions. 

Alexandria, Virginia: National Center for Missing & Exploited Children, 1995.

Rabun, John B., Jr. “Ask the Experts.” AWHONN Voice, Vol. 3, No. 6 (June/July

1995), p. 9.

Ankrom, Larry G. and Cynthia J. Lent. “Cradle Robbers: A Study of the Infant 

Abductor.” FBI Law Enforcement Bulletin, Vol. 64, No. 9 (September 1995), pp. 12-17.

Burgess, Ann Wolbert; Allen G. Burgess, Elizabeth B. Dowdell, et al. “Infant 

Abductors.” Journal of Psychosocial Nursing, Vol. 33, No. 9 (1995), pp. 30-37.

Burgess, Ann W.; Elizabeth B. Dowdell; Carol R. Hartman, et al. “Infant Abduction: A Family Crisis.” Crisis Intervention, Vol. 2, No. 2 (1995), pp. 95-110.

Unger, Thomas F. and Arthur Strauss. “Individual-Specific Antibody Profiles as

a Means of Newborn Infant Identification.” Journal of Perinatology, Vol. 15, No. 2 

(1995), pp. 152-155.

80 - For Healthcare Professionals
Aldridge, Geoffrey M. “Protecting Hospitals Against Infant Abductions.” Journal 

of Healthcare Protection Management, Vol. 12, No. 1 (Winter 1995/1996), pp. 72-80.

1996

Colling, Russell L. Security: Keeping The Health Care Environment Safe. Oakbrook 

Terrace, Illinois: The Joint Commission, 1996.

Rabun, John B., Jr.; Ann W. Burgess; and Elizabeth B. Dowdell. “Infant Abduction in the Hospital.” Creating a Secure Workplace: Effective Policies and Practices 

in Health Care. Editors John R. Lion, William R. Dubin, and Donald E. Futrell. 

United States of America: American Hospital Publishing, Inc., 1996.

1997

Karpovich, Jeff. “Understanding National Guidelines for Infant Abduction Prevention and Response.” Journal of Healthcare Protection Management, Vol. 13, No. 1 

(Winter 1996/97), pp. 63-67.

Quayle, Catherine. “Robbing the Cradle: Hospitals Have Learned the Hard Way 

That One Stolen Baby Is One Too Many.” Health Facilities Management, Vol. 10, 

No. 8 (August 1997), pp. 20-27.

1998

Provincial Ministry of Health. “Survey of Newborn Security in British Columbia 

Hospitals.” Journal of Healthcare Protection Management, Vol. 14, No. 1 (Winter 

1997/98), pp. 16-26.

American Society of Industrial Security (ASIS). Security Business Practices Reference. Alexandria, Virginia: ASIS, 1998.

1999

Sentinel Event Alert. Oakbrook Terrace, Illinois: The Joint Commission, April 9, 1999.

Roll, Fredrick G. “Nursery Crimes.” Health Facilities Management, Vol. 12, No. 9 

(September 1999), pp. 28-32.

Patient’s Rights, 42 C.F.R. § 482.13 (1999).

2000

Rabun, John B., Jr. “NCMEC: clarification of statement on electronic bracelets.”

Journal of Healthcare Protection Management, Vol. 16, No. 1 (Winter 1999/2000), pp.

120-121.

American Society of Industrial Security (ASIS). Security Business Practices Reference. Vol. III. Alexandria, Virginia: ASIS, 2000.

For Healthcare Professionals - 81
Sells, David H., Jr. Security in the Health Care Environment. Gaithersburg, Maryland: Aspen Publishers, Inc., 2000.

Steiner, Paul J., Jr. “Abducting the Abductors.” Security Management, Vol. 44, No. 

3 (March 2000), pp. 48-56.

2001

American Society of Industrial Security (ASIS). Security Business Practices 

Reference. Vol. IV. Alexandria, Virginia: ASIS, 2001.

Colling, Russell L. Hospital and Healthcare Security. 4th edition. Boston, Massachusetts: Butterworth-Heinemann, 2001.

2002

Burgess, Ann W.; Timothy Baker; Cathy Nahirny; John B. Rabun, Jr. “Newborn 

Kidnapping by Cesarean Section.” Journal of Forensic Sciences, Vol. 47, No. 4 (July 

2002), pp. 827-830.

Nahirny, Cathy. “Trends in infant abduction.” Journal of Healthcare Protection 

Management, Vol. 18, No. 2 (Summer 2002), pp. 30-34.

Security Issues For Today’s Health Care Organization. Oakbrook Terrace, Illinois: 

The Joint Commission, 2002.

Sarratt, Walter G. Hospital Security Professionals’ Manual: An Assessment and Planning Guide. Marblehead, Massachusetts: Opus Communication, 2002.

Baker, Timothy; Ann W. Burgess; John B. Rabun, Jr.; Cathy Nahirny. “Abductor 

Violence in Nonfamily Infant Kidnapping.” Journal of Interpersonal Violence, Vol. 

17, No. 11 (November 2002), pp. 1218-1233.

Madden, Jeanne M.; Stephen B. Soumerai; Tracy A. Lieu; Kenneth D. Mandl; 

Fang Zhang; Dennis Ross-Degnan. “Effects of a Law against Early Postpartum

Discharge on Newborn Follow-up, Adverse Events, and HMO Expenditures.”

The New England Journal of Medicine, Vol. 347 (December 19, 2002), pp. 2031-2038.

2003

Butler, Alan J. “Infant abduction: prevention through a multidisciplinary and 

multidimensional approach.” Journal of Healthcare Protection Management, Vol. 19, 

No. 1 (Winter 2003), pp. 87-98.

Steiner, Paul J. “Planning for and preventing infant abductions in the healthcare 

environment.” Journal of Healthcare Protection Management, Vol. 19, No. 2 (Summer 2003), pp. 92-97.

82 - For Healthcare Professionals
2004

Colling, Russell. “The ‘body of knowledge’ in healthcare security.” Journal of 

Healthcare Protection Management, Vol. 20, No. 2 (Summer 2004), pp. 1-7.

2005

Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook 

Terrace, Illinois: The Joint Commission, 2005.

Nahirny, Cathy. “Trends in Infant Abductions.” Journal of Healthcare Protection 

Management. Vol. 21, No. 2 (Summer 2005), pp. 95-99.

2006

Serious Reportable Events in Healthcare 2006 Update: A Consensus Report. Washington, DC: National Quality Forum, 2007

2007

Wood, Debra Anscombe. “Keeping Baby Safe & Sound.” The Nursing Spectrum. 

(July 2, 2007), http://include.nurse.com/apps/pbcs.dll/article?AID=2007306250020.

2008

Burgess, Ann Wolbert; Kathleen E. Carr; Cathy Nahirny; and John B. Rabun. 

“Nonfamily Infant Abductions, 1983-2006.” American Journal of Nursing, Vol. 108, 

No. 9 (September 2008), pp. 32-38.

Glasson, Linda; Fay A. Rozovsky; and Meg Gaffney. “Security Challenges and

Risk Management Strategies for Child Abduction.” Journal of Healthcare Protection 

Management, Vol. 24, No. 1 (2008), pp. 78-86.

McKinnon, Joseph F. “Infant Abduction: Taking A New Look at ‘False’Alarms.”

Journal of Healthcare Protection Management, Vol. 24, No. 1 (2008), pp. 87-90.

2009

“09. Areas of Higher Risk: 02. Infant/Pediatrics Security.” Healthcare Security: 

Basic Industry Guidelines. Glendale Heights, Illinois: International Association for 

Healthcare Security and Safety, January 2009.

For Healthcare Professionals - 83
The National Center for Missing & Exploited Children® (NCMEC) was established 

in 1984 as a private, nonprofit organization. Per 42 U.S.C. § 5773 NCMEC fulfills

19 core federal mandates including the operation of a national, 24-hour, toll-free 

telephone line by which individuals may report information regarding the location of a missing child and request information about the procedures necessary to 

reunite a child with his or her legal custodian; operation of the national resource 

center and information clearinghouse for missing and sexually exploited children;

coordination of programs to locate, recover, or reunite missing children with their 

families; provision of technical assistance and training in the prevention, investigation, prosecution, and treatment of cases involving missing and sexually exploited

children; and operation of a CyberTipline® for reporting Internet-related,

child-sexual exploitation.

A 24-hour, toll-free telephone line, 1-800-THE-LOST® (1-800-843-5678), is available in Canada and the United States for those who have information regarding 

missing and sexually exploited children. The “phone free” number is 001-800-843-

5678 when dialing from Mexico and 00-800-0843-5678 when dialing from many other

countries. For a list of other toll-free numbers available when dialing from specific

countries visit www.missingkids.com, and from the home page respectively click 

on the “More Services” and “24-Hour Hotline” links. The CyberTipline is available 

worldwide for online reporting of these crimes at www.cybertipline.com. The TTY 

line is 1-800-826-7653.

NCMEC offers free technical assistance by telephone or on-site and a complimentary copy of For Healthcare Professionals: Guidelines on Prevention of and Response to Infant Abductions by calling toll-free 1-800-THE-LOST 

(1-800-843-5678). Below is a summary of the services NCMEC offers in regard to

the prevention and resolution of infant abductions and as detailed throughout these 

guidelines. NCMEC

n	 Studies infant abductions from birthing/healthcare facilities, homes, and other

sites, in conjunction with others, and considers them preventable in large part

by “hardening the target” as described in these guidelines

n Has trained more than 64,000 healthcare professionals and conducted more than 

1,000 on-site assessments of healthcare facilities to help “harden the target” and 

reduce infant abductions from these facilities

n Provides technical assistance to healthcare facilities, law enforcement, and 

families, when infants are abducted

n	 Offers assistance to facilities when assessing and handling posttraumatic-stress

disorder (PTSD) among staff members impacted by an abduction

n Encourages distribution of “What Parents Need to Know,” found beginning on 

page 51, by healthcare facilities to patients who will be giving birth to children 

in their facility

n Provides additional information about related articles from popular magazines 

and newspapers regarding infant abductions

84 - For Healthcare Professionals
In addition a number of publications are available free-of-charge in single copies 

by writing to Administrative Services, National Center for Missing & Exploited

Children, Charles B. Wang International Children’s Building, 699 Prince Street,

Alexandria, Virginia 22314-3175.

Note: Safeguard Their Tomorrows, an educational DVD for healthcare professionals, 

has been produced by Mead Johnson Nutrition in cooperation with NCMEC. For 

more information about this free resource contact your local Mead Johnson Nutrition medical sales representative.

This project was supported by Grant No. 2007-MC-CX-K001 awarded by the Office

of Juvenile Justice and Delinquency Prevention, Office of Justice Programs, U.S.

Department of Justice. Points of view or opinions in this document are those of 

the author and do not necessarily represent the official position or policies of the

U.S. Department of Justice.

For Healthcare Professionals: Guidelines on Prevention of and Response to Infant 

Abductions was previously published as For Healthcare Professionals: Guidelines on 

Preventing Infant Abductions and For Hospital Professionals: Guidelines on preventing 

abduction of infants from the hospital. The second edition of this publication received 

the 1991 Russell L. Colling Literary Award from the International Association for 

Healthcare Security and Safety.

First Edition, Issued May 1989

Second Edition, Issued March 1991

Second Edition, Revised, Issued March 1992

Third Edition, Issued June 1993

Fourth Edition, Issued June 1996

Fifth Edition, Issued June 1998

Sixth Edition, Issued March 2000

Seventh Edition, Issued January 2003

Eighth Edition, Issued April 2005

Ninth Edition, Issued January 2009

Printed on Recycled Paper

For Healthcare Professionals - 85


01-09-014-9/NCMEC Order #05

For Healthcare Professionals:

Guidelines on Prevention of and

Response to Infant Abductions

1. The Problem

2. The Offender and Modes of Operation

3. Guidelines for Healthcare Professionals

4. Liability

5. After Discharge/Transfer from a Maternal-Child-Care Unit

6. What Parents Need to Know

7. Self-Assessment for Healthcare Facilities

8. Bibliography

Official Sponsor of the National Center for

Missing & Exploited Children

www.meadjohnson.com