Background: Previous surveys have reported variation in transfusion practice or policies in specific pediatric populations. Our objective was to determine the current transfusion policies in US and Canadian children's hospitals for both neonatal and pediatric general populations. STUDY DESIGN AND METHODS: US and Canadian blood bank (BB) personnel at children's hospitals that provide blood products between the dates of October 2008 and January 2009 were surveyed. RESULTS: Of the 90 US and Canadian children's hospitals identified, 51 (56.7%) blood bankers or their designees responded. There were 42 of 51 (82.4%) respondents from the United States and 9 of 51 (17.6%) from Canada. There was wide variation in beliefs regarding the effect of red blood cell (RBC) storage age on outcomes with 66.6% of respondents interested in a prospective randomized trial in critically ill children. There was also wide variation in policies restricting the storage age of RBCs according to patient age and clinical condition. In the United States 28 of 33 (84.8%) respondents provide universal leukoreduction of RBCs whereas it is 9 of 9 (100%) in Canada. Variation of policies existed for RBC irradiation and washing. The majority of respondents indicated that RBC transfusions were audited if the pretransfusion hemoglobin level was more than 8 to 10 mg/dL. Fresh whole blood is available at 6 of 40 (15%) responding children's hospitals. CONCLUSIONS: There is a wide variation in BB policies regarding RBC transfusions at children's hospitals in the United States and Canada. Prospective randomized controlled trials are needed to allow for evidence-based standards of care regarding RBC transfusions.