What is the recommended fluid resuscitation protocol for a pediatric burn patient, including the weight‑based lactated Ringer’s (LR) formula (4 mL × % total body surface area burned × body weight in kg), timing of administration, urine output targets (≥1 mL/kg/h or ≥0.5 mL/kg/h with head injury), electrolyte and glucose monitoring, and adjustments for inhalation injury or head injury?

Fluid Resuscitation in Pediatric Burns

Initial Bolus Resuscitation

Administer 20 mL/kg of lactated Ringer's solution intravenously within the first hour of presentation, regardless of burn size, to address early hypovolemic shock. 1, 2

• This immediate bolus should not be delayed while calculating precise total body surface area (TBSA) burned 2
• Establish IV access as soon as possible, preferably in unburned areas 1
• Lactated Ringer's (or Hartmann's solution) is the first-line crystalloid because it has electrolyte concentrations closer to plasma and avoids hyperchloremic acidosis associated with 0.9% NaCl 1, 2

Formal Fluid Resuscitation Protocol

Indications for Formal Resuscitation

Children with burns ≥10% TBSA require formal fluid resuscitation using the Modified Parkland Formula. 1, 2, 3

Modified Parkland Formula for Pediatrics

Calculate total 24-hour fluid requirement as: 3-4 mL/kg × body weight (kg) × % TBSA burned 1, 2, 3

• Use 4 mL/kg/%TBSA (the higher end) for deep partial-thickness or full-thickness burns 1, 3
• Use 4 mL/kg/%TBSA when inhalation injury is present 2
• In practice, children typically require approximately 6 mL/kg/%TBSA over the first 48 hours 2, 3

Timing of Administration

Give half of the calculated 24-hour volume in the first 8 hours from the time of injury (not from presentation), and the remaining half over the next 16 hours. 1, 2, 3

• The clock starts at the time of burn injury, not hospital arrival 2
• If the patient presents late, adjust the first 8-hour portion accordingly 2

Maintenance Fluids

Add baseline maintenance fluid requirements (using the Holliday-Segar 4-2-1 rule) to the Parkland-derived resuscitation volume. 2

• Consider using dextrose-containing normal saline (DNS) as maintenance fluid in addition to lactated Ringer's for resuscitation to prevent hypoglycemia and hyponatremia 4
• Lactated Ringer's alone is insufficient for maintenance because it is low in sodium (130 mEq/L), low in potassium (4 mEq/L), and contains no glucose 4

Monitoring and Adjustment Targets

Primary Endpoint: Urine Output

Target urine output of 0.5-1 mL/kg/hour in children; this is the simplest and fastest parameter for guiding fluid adjustments. 1, 2, 3

• Urine output <0.5 mL/kg/hour indicates under-resuscitation and requires increased fluid rate 2
• Adjust fluid infusion rates promptly based on urine output rather than rigidly adhering to formula calculations 2

Special Consideration: Head Injury

In children with concomitant head injury, target a lower urine output of ≥0.5 mL/kg/hour (rather than 1 mL/kg/hour) to avoid cerebral edema from over-resuscitation. 2

• Hypotonic solutions such as lactated Ringer's should be used cautiously in severe head trauma, though this creates a clinical dilemma in burn patients where LR is the preferred resuscitation fluid 5

Secondary Monitoring Parameters

Monitor the following parameters to guide resuscitation:

• Mean arterial pressure (MAP) >65 mmHg as a target for adequate perfusion 2
• Serum lactate levels: should normalize within 24-32 hours; serial measurements should show a downward trend with adequate resuscitation 2
• Central venous pressure (CVP) of 8-12 mmHg can be used as an adjunct in hemodynamically unstable patients, but should not be used in isolation 2
• Arterial blood gases to assess acid-base status 2

Electrolyte and Glucose Monitoring

Monitor serum electrolytes and glucose closely during resuscitation:

• Check sodium levels regularly; lactated Ringer's alone may cause hyponatremia (54% of patients on day 1, increasing to 76% by day 3 when LR is used exclusively) 4
• Monitor blood glucose levels; adding dextrose-containing maintenance fluids helps maintain glucose levels in the 115-165 mg/dL range 4
• Check potassium, calcium, and other electrolytes as clinically indicated 2

Special Considerations

Inhalation Injury

Inhalation injury significantly increases mortality and fluid requirements; use the higher end of the Parkland range (4 mL/kg/%TBSA). 2

• Look for circumoral burns, oropharyngeal burns, carbonaceous sputum, and facial burns as indicators 6
• Consider early intubation and advanced airway management 6

Electrical Burns

Electrical burns cause deeper tissue damage than apparent on surface examination and may require higher fluid volumes than predicted by surface TBSA. 2

Circumferential Burns

Monitor for circulatory compromise from circumferential burns and consider escharotomy if perfusion is compromised. 1

Critical Pitfalls to Avoid

Avoid "Fluid Creep" (Over-Resuscitation)

Over-resuscitation causes significant morbidity including compartment syndrome, pulmonary edema, intestinal edema, and acute kidney injury. 1, 2

• Studies show 76% of resuscitations exceed the upper Parkland limit, averaging 6.3 mL/kg/%TBSA 1, 2
• Do not continue excessive fluid rates once adequate urine output is achieved 2

TBSA Assessment Errors

Use the Lund-Browder chart (pediatric version) for TBSA calculation, not the Rule of Nines. 1, 2

• The Rule of Nines overestimates TBSA in 70-94% of pediatric cases, leading to fluid over-administration 2
• Reassess TBSA during initial management to prevent both overtriage and undertriage 2

Formula Limitations

No fluid resuscitation formula has been rigorously validated; formulas provide only an initial estimate. 2

• Actual infusion rates must be continually adjusted based on clinical response 2
• Children have a higher body surface area-to-weight ratio than adults, making adult formulas inadequate 3

Inadequate Initial Training

Emergency department physicians often have insufficient knowledge about pediatric burn resuscitation and require ongoing training. 7

• Only 26% of emergency physicians correctly identified lactated Ringer's as the appropriate first-line fluid 7
• Only 11% correctly identified the Lund-Browder scheme for pediatric TBSA calculation 7

Transfer Criteria

Contact a burn specialist early to determine need for transfer to a specialized burn center. 1

• Children with burns ≥10% TBSA typically require burn center care 1, 6
• Major burns (≥25% TBSA or ≥10% full-thickness) should be transferred to a burn center 6