Pediatric massive transfusion is a time-critical intervention in which uncontrolled hemorrhage may rapidly causing developmental hemostatic differences, dilutional coagulopathy, hypothermia, acidosis, and electrolyte disturbance, leading to substantial morbidity and mortality. In contrast to adult practice, pediatric transfusion management remains less standardized, and bedside decisions are still frequently influenced by extrapolated evidence, local protocols, and clinician judgment. This review aimed to summarize a practical, safety-oriented approach to pediatric massive transfusion, with emphasis on perioperative assessment, monitoring, activation criteria, transfusion protocols, and prevention of transfusion-related complications.We performed a narrative review of literature published between 2018 and 2026. Priority was given clinical practice guidelines, expert consensus documents, systematic reviews, and clinically relevant observational studies addressing pediatric major hemorrhage, trauma, cardiac surgery, extracorporeal support, viscoelastic testing, tranexamic acid, whole blood, and patient blood management. Evidence was selected for clinical relevance to perioperative anesthesia practice and synthesized theme.Safe pediatric massive transfusion requires early recognition of major bleeding, timely protocol activation, balanced and goal-directed blood product delivery, close hemodynamic and hemostatic reassessment, and active prevention of predictable metabolic and transfusion-related complications. Overall, the current literature supports a restrictive, physiology-guided approach while underscoring the need for stronger prospective pediatric evidence