Aims & Objectives: Dengue, a significant vector-borne disease, progresses through febrile, critical, and convalescent stages, with some patients entering the critical phase requiring blood products. This study investigates factors associated to transfusions in pediatric patients hospitalized with dengue and warning signs in a Bolivian hospital. Methods: We conducted a retrospective cohort study using clinical records from pediatric patients at the Maternoinfantil Bolivian Hospital in Trinidad, Bolivia, from 2019 to 2023. We analyzed demographic, clinical, and laboratory profiles, treatments, and outcomes. Cases receiving transfusions were compared to non-transfused cases, serving as markers for dengue severity. Results: Of 238 admitted patients, average age of 8±3 years, 49% female, symptoms appeared for a median 4.6 days (IQR 3.5-5.5) before admission. Transfusions were required in 29 cases. Factors associated with transfusion included pleural effusion (45% vs. 10%, p < 0.001), ascites (48% vs. 9%, p < 0.001), hepatomegaly (38% vs. 14%, p = 0.002), leukocytosis (>15,000 cells/mm³) (21% vs. 2%), along with thrombocytopenia, anemia, and prolonged coagulation times. Slow capillary refill (>3 seconds) (38% vs. 9%), hypotension, and the need for vasoactive agents were also more common (11% vs. 0%, p < 0.001). All six fatalities occurred in the transfused group. Conclusions: Patients showing significant endothelial damage and fluid leakage, rather than bleeding, were more likely to require transfusions with worse outcomes. Early hydration upon detecting warning signs is crucial to alter the clinical course effectively. Keywords: Dengue, Transfusion, Outcome assessment, Warning signs, Signs and Symptoms