Examine the relationship between brain structure and cognition in preterm children randomly assigned to a liberal red blood cell (RBC) transfusion strategy as neonates. Intelligence, achievement, and neuropsychological measures were assessed and structural imaging was obtained (n = 26; 38% male). Global brain volumes were related to cognitive outcome. Additionally, females performed lower on verbal fluency; lower performance was related to temporal white matter volume. Findings provide possible evidence of the adverse effect of a liberal RBC transfusion strategy in which females had decreased temporal lobe white matter directly related to poor verbal fluency.