The trigger for the Italian commentary was an earlier article in the same journal, in which Womack-Martenson and colleagues reported on providers’ perceptions of neonatal back transport in the United States, documenting both how often it occurs and the barriers that clinicians encounter when organizing it. Bellini and his co-authors, Maurizio Gente, Francesca Catani, and Maria del Carmen Rodriguez Perez, responded by sharing insights drawn from Italy’s own experience, where neonatal transport services have been organized at a national level for years and where the practice of returning recovering infants to referring hospitals is formally embedded in regional care networks.

The numerical core of the Italian contribution comes from a recent nationwide survey conducted by the Neonatal Transport Study Group. That survey, published in the journal Children in 2025 under the title describing the organization and activities of neonatal emergency transport in Italy, revealed that approximately 8.5 percent of all neonatal transports in the country involve back transport. This figure aligns closely with the results of a previous national survey, published in the Italian Journal of Pediatrics in 2019, which reported a rate of 9.4 percent. The near-identical values across two survey waves, conducted years apart, suggest that the frequency of back transport in Italy has remained remarkably stable over time.

That stability, the authors argue, is itself informative. It indicates that back transport is not an occasional logistical exception but a consistent, structural component of regionalized neonatal care. In a system where the sickest infants are concentrated in high-level intensive care units regardless of where they are born, a predictable fraction of those infants will eventually be well enough to continue convalescence in a level two unit nearer their families. The Italian data suggest that this fraction hovers at roughly one in twelve of all neonatal transports, a proportion large enough to warrant dedicated planning, standardized protocols, and dedicated resources rather than ad hoc arrangements.

The technical logic of back transport rests on the same principles that govern emergency retrieval, only in reverse. A convalescing infant may still require respiratory support, monitored thermal care, enteral or parenteral nutrition, and continuous observation of vital signs during the journey. The transport environment, whether a specially equipped ambulance or another vehicle configured for neonatal care, must therefore replicate a meaningful subset of the intensive care unit’s capabilities. Teams must anticipate the physiological stresses of movement, including changes in ambient pressure and vibration, the difficulty of performing procedures in a confined space, and the need to secure airways, vascular access, and equipment against the forces of acceleration and braking. Although the infant is by definition stable enough to travel, the margin for error is narrow, and the organization of the transfer determines whether the journey is a routine step in recovery or an avoidable hazard.

Bellini and colleagues emphasize that these operational realities make standardized definitions and organizational policies essential. Without a shared, precise definition of what constitutes back transport, health systems cannot measure it accurately, compare their performance across regions, or plan capacity. The Italian study group has worked for years on exactly this problem, producing national recommendations for the organization of the neonatal emergency transport service, most recently in a second edition published by the Italian Society of Neonatology in 2021. Those recommendations formalize how transport teams are staffed, how vehicles are equipped, how communication between the sending and receiving units is managed, and how the specific needs of convalescing infants differ from those of infants being retrieved in emergencies.

The Italian context is particularly instructive because of the country’s deliberate regionalization of perinatal care. Over the past decades, Italy has concentrated the care of the smallest and sickest newborns in tertiary intensive care units while maintaining a network of level two units in community hospitals. Research by the same group, published in Acta Paediatrica in 2017, examined the impact of this regionalization on transporting neonatal patients back from intensive care units to referring level two units, finding that the structure of the regional network directly shapes how often and how smoothly these return journeys happen. In a well-regionalized system, back transport is the natural mechanism by which scarce intensive care beds are freed for new emergencies while infants reconnect with their local communities and families earlier in the recovery process.

The benefits of this model extend beyond bed management. Prolonged stays in distant tertiary centers impose well-recognized burdens on families, including travel costs, separation from siblings and support networks, and the psychological strain of having a newborn hospitalized far from home. Returning a convalescing infant to a nearby unit restores proximity at a stage when bonding, breastfeeding establishment, and family participation in care become central to long-term outcomes. At the same time, the referring hospital regains the opportunity to complete the care it initiated, reinforcing clinical continuity and keeping community-level neonatal skills sharp. Back transport, in this light, is not merely a reverse ambulance ride but a deliberate act of care coordination that closes the loop opened by the original emergency retrieval.

Yet the American study that prompted the Italian response highlights that the practice faces persistent barriers. Providers reported obstacles ranging from unclear criteria for when an infant is ready to travel, to difficulties arranging appropriate vehicles and staff, to ambiguities over which service is responsible for the journey. The Italian authors’ contribution is to show that such barriers are not inevitable. A system that treats back transport as an integral, measured, and governed component of neonatal care, with national recommendations, dedicated study groups tracking activity through repeated surveys, and explicit organizational policies, can sustain a stable back transport rate over many years. The consistency of the Italian figures, at 8.5 percent in the most recent survey against 9.4 percent in the earlier one, functions as indirect evidence that institutionalized processes produce predictable practice.

The broader message for the international neonatal community is that the full lifecycle of neonatal transport, from emergency retrieval to convalescent return, should be designed, measured, and resourced as a single continuum. As regionalized perinatal networks expand in many countries, the volume of back transport will grow in proportion, and systems that lack standardized definitions and policies will accumulate the same frictions documented among American providers. The Italian experience, distilled in this correspondence, suggests a practical template: define the activity precisely, survey it nationally on a recurring basis, embed it in formal recommendations, and treat the return journey as an essential link in the chain of care rather than an afterthought. For the infants concerned, the difference between an improvised transfer and a well-orchestrated one is measured in safety, comfort, and how soon they finally arrive home.

Subject of Research: Neonatal back transport of convalescing infants within regionalized perinatal care networks

Article Title: Neonatal transport for convalescing infants

Article References: Bellini, C., Gente, M., Catani, F., Rodriguez Perez, M. D. C., & on behalf of Neonatal Transport Study Group of the Italian Society of Neonatology (2026). Neonatal transport for convalescing infants. Journal of Perinatology. https://doi.org/10.1038/s41372-026-02909-1

Image Credits: AI Generated

DOI: 10.1038/s41372-026-02909-1

Keywords: neonatal transport, back transport, convalescing infants, neonatal intensive care, regionalized care, Italian Society of Neonatology, Journal of Perinatology, nationwide survey, health care organization, level two units, transport teams, perinatal networks