Red blood cell (RBC) transfusion is crucial in treating anemia in the pediatric intensive care unit (PICU), though safety and necessity concerns persist. This prospective observational study examined the frequency and predictors of RBC transfusions among critically ill children, highlighting implications for low- and middle-income countries (LMICs). A single-center observational study enrolled 104 children admitted to a PICU from January to September 2021. Demographic details, past medical history, Pediatric Index of Mortality-3 scores, sedation, inotrope administration, ventilator-associated pneumonia (VAP), new-onset shock, respiratory failure, sepsis, renal failure, new or progressive multiple organ dysfunction syndrome (MODS), and duration of ventilation were recorded. Our results showed that 37 patients (35.6%) received RBC transfusions. The mean pre-transfusion hemoglobin level was 6.58 grams per deciliter (g/dl) (SD 1.71). The transfused group required more sedation (P <
.001) and vasoactive agents (P <
.001), had longer PICU stays (P = .013), and developed VAP (P = .037), new-onset shock (P = .025), respiratory failure (P = .021), and MODS (P = .023) more often than the non-transfused group. Logistic regression analysis showed that hemoglobin >
10 g/dl at admission reduced the odds of RBC transfusion [odds ratio (OR) = 0.57, confidence interval (CI) = 0.43-0.74], while sepsis at admission increased the odds (OR = 3.24, CI = 1.09-9.60). The current study demonstrates that about one-third of critically ill children received RBC transfusions. Hemoglobin above 10 g/dl at admission was associated with significantly lower odds of RBC transfusion, while sepsis at admission significantly increased the odds. These findings are particularly relevant for LMICs, where resource constraints necessitate careful evaluation of transfusion practices to optimize patient outcomes and resource utilization.