Whole blood and its main components—red cells, white cells, platelets, and plasma—are prohibited as blood transfusions under Jehovah’s Witness teachings. Medical decisions made on a dependent child’s behalf must be made in the child’s best interest, allowing for maximal benefit with the least harm. Informed consent discussions with a Jehovah’s Witness patient and family regarding perioperative blood transfusions implicate both legal and ethical aspects of patient refusal. Some children are presumed to have capacity to make reasoned medical decisions based on their age or by evidence of maturity indicating an ability to understand the consequences of their decisions. Today, parents in the USA may not refuse a lifesaving transfusion for their child when the benefit outweighs the risk of death or imminent harm. Patient blood management (PBM) includes the use of evidence-based surgical and medical concepts to maintain perioperative hemoglobin concentration, optimize hemostasis, and minimize blood loss. These pillars of PBM can be applied to all phases of pediatric perioperative care and should be incorporated into the perioperative process. Within each pillar, there are techniques and alternatives that can be personalized for each patient.