Objective To develop a predictive model for guiding blood transfusion decisions in pediatric patients with traumatic brain injury （TBI） by identifying and analyzing key factors that influence blood transfusion requirements. Methods A retrospective analysis was conducted on the clinical data of 1，535 pediatric patients with TBI admitted to four medical institutions from January 1， 2015， to December 31， 2022. Patients were divided into two groups： those who received red blood cell transfusions during hospitalization and those who did not. Comparative analyses were performed on demographic， clinical， and laboratory data between these two groups. Logistic regression analysis was used to identify risk factors associated with in-hospital blood transfusion， and a predictive model was developed using a nomogram. The performance of this model was evaluated using a receiver operating characteristic （ROC） curve. Results Significant differences were observed between the blood transfusion and non-blood transfusion groups in terms of baseline demographics， clinical indicators， and laboratory test results （all P < 0.05）. Patients in the blood transfusion group exhibited significantly higher in-hospital mortality， complication rates， use of mechanical ventilation， ICU admission rates， and length of stay compared to those in the non-blood transfusion group （all P < 0.05）. Multivariate logistic regression analysis identified heart rate， presence of other fractures， treatment methods， hemoglobin （Hb）， platelet count （Plt）， activated partial thromboplastin time （APTT）， and D-dimer levels as independent risk factors for blood transfusion in TBI patients. The area under the ROC curve for the blood transfusion prediction model， based on these independent risk factors， was 0.95 （95%CI： 0.94 ~ 0.97）， indicating excellent predictive accuracy. Calibration and decision curves further validated the robustness and reliability of the model's predictive capacity. Conclusions Heart rate， presence of other fractures， treatment methods， Hb， Plt count， APTT， and D-dimer levels serve as independent risk factors for blood transfusion in TBI patients. The prediction model developed based on these factors demonstrates excellent predictive performance， thereby guiding clinicians in making informed blood transfusion decisions and enhancing the success rate of patient outcomes.