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Background Preterm neonates, particularly those with extremely low birth weight and gestational age, are at high risk of requiring multiple blood transfusions during their stay in the neonatal intensive care unit (NICU). Repeated transfusions result in multiple donor exposures, leading to increased risk of infections, alloimmunisation, worse neurodevelopmental outcomes and transfusion-related complications. Optimising transfusion practices through prediction-based strategies could enhance safety and resource efficiency, particularly in low- and middle-income countries.Objective This study aims to evaluate transfusion patterns among preterm neonates and develop a predictive model based on birth weight and gestational age to reduce donor exposure and improve transfusion efficiency.Methods This retrospective observational study included inborn preterm neonates (gestational age 23+0 to 32+0 weeks) admitted to a tertiary care NICU in South India in 2023 who received at least one packed red blood cell (PRBC) transfusion. Outborn babies who were transferred to the NICU beyond 48 hours of life and babies needing surgery at any point during their NICU stay were excluded. Data on gestational age, birth weight, transfusion frequency, donor exposure, clinical outcomes and blood usage were analysed. Predictive models were developed using Bayesian ordinal regression to estimate transfusion requirements.Results We analysed 422 PRBC transfusions administered to 118 neonates. Lower gestational age and birth weight were significantly associated with increased transfusion frequency and donor exposure. Predictive models using gestational age and birth weight reduced the need for multiple donors. This approach, if used, would have also improved blood resource planning and highlighted the potential for reduced wastage.Conclusion Individualised transfusion strategies may reduce donor exposure and improve transfusion safety in preterm neonates, especially in resource-limited settings.