Objective To investigate the effects of red blood cell transfusions and transfusion strategies on clinical outcomes in extremely low gestational age neonates (ELGANs). Methods This retrospective cohort study enrolled 545 ELGANs with gestational age 28 weeks admitted between 2012 and 2024. Infants were divided into transfusion and non-transfusion groups. Tra nsfused infants were further classified into restrictive, liberal, and relatively liberal transfusion groups according to transfusion thresholds, and intergroup differences in clinical outcomes were analyzed. Multivariate logistic regression was performed to analyze the independent association between transfusion and outcomes, adjusted for treatment era (2012–2019 vs. 2020–2024), perinatal factors, postnatal illness severity, and treatment-related variables. Primary outcomes were bronchopulmonary dysplasia (BPD) and survival without severe complications. Secondary outcomes included severe retinopathy of prematurity (ROP), necrotizing enterocolitis (NEC), severe brain injury, and death. Results A total of 545 ELGANs were included, with a median gestational age of 26.5 (IQR 25.6–27.2) weeks. Among them, 346 infants (63.5%) received at least one transfusion, with a total of 798 transfusion episodes and a median number of transfusions of 2 (IQR 1–3). Of the transfused infants, 82 (25.0%) were in the restrictive transfusion group, 138 (39.9%) in the liberal transfusion group, and 92 (26.6%) in the relatively liberal transfusion group. An increased number of transfusions was an independent risk factor for BPD (adjusted OR = 1.88, 95% CI: 1.48–2.40, p 0.001) and was independently associated with a lower rate of survival without severe complications (adjusted OR = 0.75, 95% CI: 0.63–0.91, p = 0.003). Meanwhile, a higher transfusion number was independently associated with lower risks of severe brain injury (adjusted OR = 0.62, 95% CI: 0.46–0.84, p = 0.002) and mortality (adjusted OR = 0.66, 95% CI: 0.53–0.83, p 0.001). Transfusion number was not independently associated with severe ROP or NEC. The restrictive transfusion group had significantly fewer transfusions than the relatively liberal transfusion group, with no significant differences in BPD, survival without severe complications, or other adverse outcomes compared with the other two groups. Conclusions In ELGANs, an increased number of transfusions is independently associated with a higher risk of BPD and lower survival without severe complications. A restrictive transfusion strategy safely reduces transfusion exposure without increasing the risk of major adverse outcomes and is recommended in clinical practice.
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