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Introduction Haemorrhage is the leading cause of early mortality in paediatric trauma patients (PTP). Many paediatric massive transfusion (MT) protocols advocate for a balanced transfusion strategy (≥1:2 FFP: Platelets: RBC), despite supportive evidence. This review aimed to determine whether balanced transfusion ratios improve 24-hour mortality in PTP undergoing MT (≥40 ml/kg total blood products in the first 24 hours).Methods A systematic review and meta-analysis was conducted in accordance with a registered PROSPERO protocol (CRD420250646674) and PRISMA guidelines. MEDLINE, EMBASE, Scopus, and CENTRAL were searched without language or date restriction. Eligible studies included PTP <18 years old who received MT and were grouped according to balanced (≥1:2) vs. unbalanced (<1:2) FFP: RBC or Platelet: RBC ratios. Primary outcome was 24-hour mortality. Secondary outcomes included in-hospital mortality, ICU/hospital length of stay, transfusion volumes, adverse events, and cost. Risk of bias and certainty of evidence were assessed using ROBINS-I and GRADE, respectively.Results Six studies with 1664 participants were included. No randomised controlled trials were identified. Meta-analysis of five studies (n=1616) demonstrated a statistically significant reduction in 24-hour mortality associated with balanced FFP: RBC transfusion (OR 0.68; 95% CI 0.52–0.88; p=0.004; I²=0%). No mortality difference was seen with balanced Platelet: RBC ratios (OR 1.02; 95% CI 0.69–1.50; p=0.92). No consistent differences were found in secondary outcomes including ICU/hospital stay, mechanical ventilation or adverse events. Most studies were at critical risk of bias due to survivorship and intervention deviation. Certainty of evidence for all outcomes was low.Abstract #42 Figure 1Forest plot of 24-hour mortality between balanced (≥1:2) FFP: RBC and unbalanced (<1:2) FFP: RBC groupsConclusion Balanced FFP: RBC transfusion appears safe and may offer an early survival benefit in PTP undergoing MT. This conclusion is limited by low-certainty evidence and high risk of bias in included studies. No benefit was observed with balanced Platelet: RBC ratios. Prospective trials are needed to validate these findings and determine optimal paediatric transfusion strategies. *presenting author