SUMMARY.Extracorporeal membrane oxygenation (ECMO) is a lifesaving therapy for neonatal pulmonary hypertension but carries a significant risk for transfusion‐related complications. Packed red blood cell (PRBC) and platelet exposure were quantified and reviewed in 17 ECMO survivors prior (Group I,n= 9) and subsequent to (Group II,n= 8) changes in transfusion protocols. Blood product requirements included ECMO circuit priming, maintenance of haematocrit>0.40 or platelet count>50 times 109/1, and colloid volume expansion. Group I was exposed to 13.8±10.2 (x±SD) different PRBC units. In Group II, multiple transfusions from single donor units decreased exposure 71% to 3.9±0.7 units (P<0.05). Decreases in blood withdrawn (11%) and transfusion volume (7%) were coincident with a 15% reduction in mean bypass time. Platelet volume transfusion decreased from 159±213 to 93±64 ml using volume‐reduced platelet packs. Total transfusion exposure decreased 59% from 20.8±17.8 units to 8.6±2.4 donor units. No transfusion complications occurred during the aggregate 1,926 h on bypass.We conclude that neonates on ECMO have a significant transfusion exposure risk increasing with prolonged duration of ECMO therapy. In addition we noted that concentrated platelet packs decreased transfusion volume by 41%, and multiple PRBC transfusions from single donor units decreased donor exposure by 71% while both strategies decreased the overall transfusion exposure r