Very-low-birth-weight (VLBW) infants often require blood transfusions for anemia. Studies have investigated the preventative effect of delayed cord clamping, high-dose iron, and costly recombinant erythropoietin. As part of our unit clinical governance framework to improving patient care, we audited the effect of a preventative management guideline that combines delayed cord clamping for 30 seconds with early protein intake and early oral iron supplementation (6 mg/kg from days 7 to 10 of life, if milk feeds 60 mL/kg/d) combined with a restrictive transfusion policy in infants < 32 weeks' gestation and < 1500 g birth weight. Data on blood transfusions in VLBW infants during the first 6 weeks of life collected before the start of the new regimen (period I) were compared with data in consecutively born VLBW infants after the introduction of the management guideline (period II). Age (in days) when milk feeds and oral iron supplements were introduced was recorded. Statistical analysis used Wilcoxon signed-rank test. VLBW infants in period I ( N = 18, median birth weight 1001 g [727; 1158]) received a median of four transfusions (0.75; 9) compared with 1.5 (0.75; 5, P = 0.01) VLBW infant transfusions in period II ( N = 22, median birth weight 967 g [792; 1131]). Milk feeds of 60 mL/kg/d were achieved on median day 12 (6; to 16), and iron was introduced on median day 38 (21; to 44) in period I compared with milk feeds on day 9 (7; 15, P = 0.05) and oral iron on day 16 (11; 21, P < 0001) in period II. The combination of a 30-second delay in cord clamping, early protein and iron, and a change of transfusion thresholds reduced the number of blood transfusions by half.