Pediatric burn fluid resuscitation

Overview¶

Fluid resuscitation in burned children rests on the same physiology that governs adult resuscitation: thermal injury triggers a capillary leak that shifts plasma from the vasculature into the wound and surrounding tissues, and replacement of that volume is required to maintain organ perfusion through the first 24 to 48 hours. The clinical envelope is narrower in children. Pediatric burn patients are more susceptible to burn shock than adults, and an effective fluid management protocol is critical to successful resuscitation ^[41]. Children have a limited physiologic reserve, and age-related limitations make adequacy of intravenous fluid resuscitation critical ^[13]. Optimal fluid resuscitation in children with major burns is crucial to prevent or minimise burn shock and the complications of over-resuscitation ^[2]. The child or infant who arrives with a major burn presents challenges that adult-derived formulae and adult-derived endpoints do not fully resolve ^[22].

The decision space is bounded by under-resuscitation, which produces burn shock, acute kidney injury, and early death, and over-resuscitation, which produces fluid creep, pulmonary edema, and compartment syndromes. Many approaches to fluid resuscitation of children after burns exist, and most are non-evidence-based ^[22]. Practice varies across pediatric burn centers in the TBSA threshold at which fluid resuscitation is initiated, the formula coefficient used, the criteria for adding dextrose-containing fluids, and the urine output goal ^[10]. Center-level variation produces statistically significant differences in fluid estimates for otherwise comparable injuries ^[10]. This page treats the durable principles (early start, weight- and surface-area-indexed crystalloid, titration to urine output, selective colloid rescue) and surfaces where the evidence is thin.

Epidemiology¶

Pediatric burns affect a population skewed toward young age and scald mechanism. In an American Burn Association Burn Care Quality Platform analysis of 99,195 patients admitted to 112 burn centers between 2020 and 2023, 23,284 were pediatric ^[40]. In a South Asian Burn Registry of 2,749 patients, the mean age was 21.7 years and about a quarter were children under five; scald burns were common among children (67.6%) while flame burns predominated among adults (44.3%) ^[43]. Approximately 75% of patients were brought in via non-ambulance mode of transport in that cohort, and the adjusted odds of being admitted versus sent home were highest for children under five ^[43].

Center volume matters for pediatric outcomes. Palmieri et al. analyzed 33,115 records of children 18 years or younger in the National Burn Repository and found that age, total body surface area, inhalation injury, and burn center volume each influenced mortality (p<0.05), with high-volume centers (admitting more than 200 pediatric patients per year) having the lowest mortality after adjusting for age and injury characteristics ^[24]. An increase in median yearly admissions of 100 decreased the odds of mortality by approximately 40% ^[24]. Higher-volume pediatric burn centers had lower mortality, particularly at larger burn sizes ^[24].

Practice patterns vary internationally. An ISBI/ABA survey reported that the Parkland formula was preferred (69.3%), with lactated Ringer's the preferred solution (91.9%); colloid use included albumin in 20.8% and fresh frozen plasma in 13.9% of responding centers, and approximately half (49.5%) added colloid before 24 hours ^[44]. A 17-year Netherlands cohort of 9,031 patients showed an increasing incidence rate of burn-related burn-center admissions with a decreasing TBSA and decreasing in-burn-centre mortality (overall 4.1%, significantly decreased over time) ^[37]. A recent comparative analysis of 618 pediatric burn patients showed regional admissions increased by 26% in 2020, whereas national data demonstrated a 41% decline; older pediatric age and thermal burns were significant risk factors ^[39].

Many pediatric patients with burn injuries may be initially treated in a hospital where pediatric specialized care, including resources and trained personnel, is limited ^[21]. This shapes the transfer environment in which the bulk of pediatric resuscitation decisions are first made. Burn epidemiology outside high-resource settings shows similar patterns. An Albanian severe-burn series spanning 2009-2019 documented an ICU burn admission incidence of 5.2 patients per 100,000 population per year, with scalds (49.6%) the most frequent etiology followed by flame (39.5%) ^[48].

Pathophysiology¶

Pediatric burn pathophysiology shares the capillary-leak mechanism that drives adult burn shock but adds three age-specific dimensions. First, children have age-related limitations of physiologic reserve, making adequacy of fluid resuscitation critical ^[13]. Pediatric patients have different pharmacokinetics and pharmacodynamics affecting which medications are used and how they are dosed ^[21]. Second, the surface-area-to-mass ratio differs by age, and children under three years require significantly more fluid and sodium during the first 48 hours when calculations are made using body weight as the indexing factor; this difference disappears when fluid and sodium needs are calculated using body surface area as the indexing factor ^[14]. The observed differences likely reflect the surface-area-to-mass ratio for these age groups ^[14]. Third, the cardiac response to severe burn differs in children: Reynolds et al. evaluated cardiac function by thermodilution in severely burned pediatric patients and found that 100% had depressed left ventricular function, with only 38% having concomitant right ventricular failure ^[17]. Left-sided dysfunction persisted throughout the acute resuscitation period but improved after appropriate modification of fluid resuscitation and initiation of vasopressor support ^[17]. Cardiogenic failure is a major determinant of a failing pediatric burn resuscitation, and, contrary to the adult burn patient, the myocardial depression is predominantly left-sided ^[17].

Body water composition shifts measurably through acute and rehabilitative phases. Prelack et al. used a combined tracer dilution method in severely burned children and found that during the acute phase, intracellular water (ICW) losses averaged 2.2 ± 2.0 liters or 18.5 ± 0.4%, and the mean ECW/ICW ratio increased from 1.06 ± 0.15 to 1.20 ± 0.14 because the extracellular compartment expanded relative to the intracellular compartment ^[31]. During rehabilitation, mean ICW increased by 3.4 ± 3.7 liters or 31.9 ± 14% ^[31]. Tracking ICW and the ECW/ICW ratio using the combined tracer dilution method is practical for monitoring body cell mass and water distribution in severely burned children ^[31].

Inflammatory mediator profiles are measurable in pediatric burn patients. Cytokine levels in pediatric burn patients increased after severe burn injuries, with a significant correlation between IL-8 levels and degree of burn injury ^[46]. Mean IL-6, IL-8, IL-10, and TNF-α were 18.15 ± 4.77, 59.54 ± 4.59, 8.41 ± 2.09, and 1.48 ± 0.15 pg/ml respectively in one pediatric cohort, all higher than normal values ^[46]. The levels of TNF-α were higher in patients with sepsis (P = 0.03) and deceased patients (P = 0.001) ^[46].

Classification¶

Children are stratified for resuscitation purposes by total body surface area burned and by age band. Most UK burns units in a national survey commenced fluid resuscitation at 10% total body surface area burn in children and 15% TBSA in adults ^[45]. Below those thresholds, maintenance fluids replace formal resuscitation. The TBSA threshold at which fluid resuscitation is initiated varies across pediatric burn centers in North American practice ^[10]. Burns are also classified by depth; full-thickness depth raises predicted volume requirements above the surface-area-based starting estimate, with the volume required to prevent post-resuscitation respiratory failure rising in proportion to the depth of the burned area ^[27].

Assessment¶

Accurate TBSA estimation is the most consequential assessment decision in pediatric burn resuscitation because it determines the predicted volume. Inaccuracies in fluid resuscitation result in, on average, patients receiving twice the appropriate volume of fluid for the burn size ^[1]. Burn-size assessment in children is harder than in adults. Chan et al. found that accurate assessment of TBSA-burned and burn depth in children remains elusive and would appear to require additional training and education ^[8]. Around 90.4% of patients on presentation had discrepancy in their burn percentage calculation in one series of transferred pediatric burn patients, where initial fluid resuscitation showed a statistically significant association with survival ^[28].

Referring-hospital overestimation is common. Sadideen et al. found that 32 of 46 children (70%) had their burns overestimated, 7 (15%) underestimated, and 7 (15%) correctly estimated at the referring institution; overestimation led to overprescription of fluid volumes but did not translate into over-resuscitation, and in most cases was in fact associated with inadequate fluid administration ^[29]. Manning Ryan et al. found that referring-facility discrepancies may trigger inappropriately aggressive interventions with potential for patient harm and showed that a quality-improvement intervention using a common clinical assessment instrument and standardization of the transfer intake process significantly improved the proportion of patients with TBSA recorded (94% versus 56%, p<0.001) and reduced clinically significant discrepancies ^[25]. Face and Dalton found that approximately half of cases (55/123 = 45%) were referred with a TBSA greater than 10% to the New South Wales Burns Unit, where just over half (33/55 = 60%) were reassessed as greater than 10%; about 40% of cases received an initial overestimation of TBSA by referring hospitals ^[26]. A Dutch nationwide evaluation of referred children documented that referring physicians overestimated burn size by a factor of two (mean difference 6% TBSA ± 5.5), that proportions of children receiving intravenous fluid resuscitation regardless of indication rose from 33% to 49% (p<0.01), and that received volumes tended to be higher than necessary ^[57]. A US prospective study of consecutive pediatric admissions to a verified pediatric burn center found significant overestimation of scald and contact burn size (p<0.05) with no difference in flame burn estimation, more frequent overestimation by community than tertiary referrers (p<0.05 vs p=0.29), and 59% of patients receiving more fluid at the referring hospital than the pediatric-center TBSA would have predicted ^[58]. A regional verified burn center review of transferred patients found that referring emergency department staff calculated a mean TBSA of 23.9% versus the burn-ICU mean of 17.8%, that only 23% of patients fell within the American Burn Association formula's accepted range, that 30% were over-resuscitated and 47% under-resuscitated, and that 33% of patients had more than a 50% TBSA discrepancy between burn unit and referring ED calculations ^[54].

Calculation method matters as much as estimation. Bodger et al. compared three techniques for Parkland formula calculation in pediatric burns: a dedicated nomogram was the most accurate method of calculating fluid requirements, was only slightly slower than the electronic calculator, and was deemed the easiest to use ^[7]. Dingley et al. randomized 21 volunteers performing 189 calculations across electronic, disc, and pen-and-paper methods and found that 65% of calculations with the electronic device, 35% using the disc, and 44% using pen/paper methods were within ±5% of the correct value; both novel devices provide safer and faster alternatives to conventional methods for calculating fluid requirements in pediatric burns ^[6].

Resuscitation endpoint selection in pediatric burns has been studied less than in adults. Six of seven studies in a systematic review of pediatric resuscitation endpoints used urine output as the primary endpoint, with targets ranging from 0.5-1.0 mL/kg/hour to 2-3 mL/kg/hour; no studies compared different urine output targets ^[2]. One study targeted invasive hemodynamic variables, but this did not significantly affect patient outcome ^[2]. Belba et al. proposed the input-output (I/O) ratio at 8 hours as an early predictor: there is a strong correlation between the I/O ratio at 8 hours and the I/O ratio at 24 hours, and the I/O ratio is associated with longer ICU-free days ^[30]. Echocardiography is emerging as a complementary endpoint: Sayın et al. in a retrospective study of 40 pediatric patients with burns covering 20% TBSA or more found that the transthoracic-echocardiography (TTE) group received fluid therapy guided by the inferior vena cava to aorta (IVC/Ao) ratio, fluid therapy was modified in 80% of patients based on echocardiographic findings, and the TTE group required less diuretic treatment (10% vs 60%, p<0.05) compared to the control group, with no significant difference in mortality between groups ^[12]. The addition of TTE to conventional methods for managing fluid resuscitation in pediatric burn patients may help reduce unnecessary fluid administration and diuretic use ^[12].

Management¶

Formula selection¶

Pediatric resuscitation formulae cluster around three families: weight-and-TBSA crystalloid formulae (pediatric Parkland 3 mL/kg/%TBSA in the Müller Dittrich RCT ^[33], distinct from the adult Parkland 4 mL/kg/%TBSA), surface-area-based formulae developed at pediatric burn centers (Galveston-Shriners and Cincinnati variants), and weight-only emergency-resuscitation rules for first-hour use. Pediatric protocol reviews calculate pathological fluid losses at 2 or 4 mL/kg/%BSAB; the 4 mL/kg/%BSAB formulae replace all theoretically predicted pathophysiologic losses, while the 2 mL/kg/%BSAB formulae are more practical as a pediatric guideline because of greater therapeutic range and better clinical response of children threatened by burn shock ^[55]. An Intermountain Burn Center series of 177 children documented a mean fluid received during burn shock resuscitation of 5.8 ± 0.25 mL/kg/%TBSA and a sodium load of 1.06 ± 0.04 mEq/kg/%TBSA, with significantly higher fluid and sodium requirements in children than in adults but no morbidity from fluid overload ^[56]. Among UK and Ireland burns units, the estimated resuscitation volume is calculated using the Parkland or the Muir and Barclay formula in 76% and 11% of units, respectively ^[45]. International practice variation is wide: Spelten et al. identified eight published formulae across the 1950-2010 literature, three recommending colloid solutions, four recommending electrolyte solutions, and one suggesting other compositions; only one formula specifically dealt with fluid resuscitation in infants, and the identified formulae led to sometimes strikingly diverse calculations of resuscitation fluid volumes ^[9]. All formulas are guides to fluid therapy and should be modified according to individual needs and clinical status of the patient ^[55].

The actual volume delivered routinely exceeds formula prediction in children. Pisano et al. compared three of five pediatric burn centers' resuscitation guidelines against the actual mean fluid received and found that the guidelines produced statistically significant lower mean fluid estimates than what was actually given (4.53 versus 6.35 mL/kg/%TBSA, p<0.001; 4.90 versus 6.35 mL/kg/%TBSA, p=0.002; 3.38 versus 6.35 mL/kg/%TBSA, p<0.0001); one center chose to modify its resuscitation guidelines at the conclusion of this study ^[10]. Graves et al. reported that the average total volume of fluid received during the first 24 hours in infants and children with massive thermal injury was 6.3 ± 2.2 cc/kg/%TBSA, with a net resuscitation volume of 3.91 ± 2.2 cc/kg/%TBSA after subtracting maintenance, and recommended supplying maintenance volume and initiating burn resuscitation at 3 cc/kg/%TBSA ^[13]. Shen et al. proposed a pediatric ten-fold rehydration formula (mL/h = body weight in kg × 10) for the first 8 hours post-injury; in 433 pediatric patients with extensive burns, the accuracy rate of the ten-fold formula was 73.92% (4,671/6,319), significantly higher than 4.02% (254/6,319) of the comparator TWGB formula, with 100% accuracy at 30-55% TBSA and 88.28% accuracy at 56-85% TBSA, falling to 0% at 86-100% TBSA in both formulae ^[11].

Crystalloid choice and starting dose¶

Lactated Ringer's is the workhorse crystalloid in pediatric burn resuscitation, used by 91.9% of responding centers in the ISBI/ABA survey ^[44]. Pediatric variations use coefficients between 2 and 4 mL/kg/%TBSA. In the Müller Dittrich randomized trial of early versus late albumin in children with burns greater than 15-45% TBSA, fluid resuscitation was based on the Parkland formula at 3 mL/kg/%TBSA, adjusted according to urine output ^[33]. In a 50-patient observational cohort, 24-hour fluid resuscitation clustered in the range 2-4 mL/kg/%TBSA, with fluid-weight score (mL/kg) correlated with %TBSA ^[30].

Reduced-volume resuscitation in moderate pediatric scalds¶

Reduced-fluid regimes for moderate-TBSA pediatric scalds preserve hydration without compromising depth-related outcomes ^[50,51]. At a UK center, children with 10-19% BSA scalds managed with biosynthetic dressings and 80% maintenance fluids (permissive hypovolemia, no formal burn resuscitation) had serum sodium and urine output comparable to traditionally resuscitated controls (median sodium 136 vs 136, p=1.00; median urine output 1.5 vs 1.8, p=0.25) ^[51]. Renal markers showed lower urea and higher creatinine in the traditional group (urea 3.2 vs 2.3, p=0.04; creatinine 21 vs 30, p<0.001), with more traditionally resuscitated patients outside reference ranges for urea (61% vs 23%, p=0.04) and creatinine (44% vs 8%, p=0.03) ^[51]. National guidelines have advocated 4 mL/kg/%BSA for pediatric burns greater than 10% BSA, but adult evidence suggests such volumes drive over-resuscitation and related complications ^[51]. In a retrospective audit at the South West Children's Burn Centre, the median length of stay per percent BSA burned was 0.27 days under a reduced-volume regime, significantly less than 0.54 and 0.50 days in pre-2007 and other England and Wales burn services (p<0.001), with skin grafting and re-admission rates preserved ^[50]. A reduced-fluid regime shortens length of stay per percent burn without compromising healing in moderate pediatric scalds ^[50].

Titration to urine output¶

Urine output is the most widely used endpoint for hour-by-hour titration. Among pediatric studies, urine output targets range from 0.5-1.0 mL/kg/hour to 2-3 mL/kg/hour ^[2]. Some pediatric protocols achieve a median urine output of approximately 2 mL/kg/hr through the first 72 hours ^[33]. Maintaining the urine output target is the operational goal of titration; volume is increased when output falls below target and decreased when output exceeds target.

Maintenance fluid integration¶

Pediatric resuscitation differs from adult resuscitation in requiring concurrent maintenance fluids, which include glucose-containing solutions to prevent hypoglycemia in younger children. The criteria for initiating dextrose-containing fluids vary across pediatric burn centers ^[10]. Graves et al. recommended supplying maintenance volume alongside burn resuscitation, with burn-shock fluids initiated at 3 cc/kg/%TBSA in addition to maintenance ^[13]. In one mixed-age cohort of 140 patients including 26 children, basic maintenance fluids were incorporated into the predicted requirement, producing median predicted requirements of 5.4 mL/kg/%TBSA, with pediatric patients showing greater calculated differences than adults ^[32]. Nutritional therapy is a cornerstone of burn care from the early resuscitation phase onward; ESPEN-endorsed recommendations call for early enteral feeding and elevated protein delivery of 3 g/kg in children, and recommend the Schofield equation for energy requirement determination in pediatric burns when indirect calorimetry is unavailable ^[47].

Early albumin and colloid rescue¶

Albumin is the most-studied colloid in pediatric burns. The Müller Dittrich randomized trial allocated 46 children aged 1-12 years with burns greater than 15-45% TBSA admitted within 12 hours of injury to receive 5% albumin between 8 and 12 hours post-burn (intervention) or at 24 hours post-burn (control) ^[33]. The median crystalloid fluid volume required during the first three days post-burn was lower in the intervention than in the control group: 2.04 vs 3.05 mL/kg/%TBSA on day 1 (p=0.025), 1.2 vs 1.71 mL/kg/%TBSA on day 2 (p=0.002), and 0.82 vs 1.3 mL/kg/%TBSA on day 3 (p=0.002) ^[33]. Fluid creep was observed in 13 controls (56.5%) and in one intervention patient (4.3%) ^[33]. The median length of hospital stay was 18 days for controls and 14 days for the intervention group (p=0.004) ^[33]. Median urine output did not differ between groups on any of the three days ^[33]. Early albumin infusion in children with burns greater than 15-45% TBSA reduced the need for crystalloid fluid infusion during resuscitation ^[33]. A separate analysis from the same cohort reported that both length of stay in the hospital and fluid creep were associated with infection (p<0.05); sepsis is currently the leading cause of death in survivors of burn shock, and patients receiving early albumin had less fluid creep (4.3% vs 56.5%), less skin graft procedure (47.8% vs 78.3%, p=0.032), and shorter length of stay (p=0.007) ^[34].

Burned children adhering to the basic tenets of burn resuscitation should have resuscitation modified based on age, physiology, and response to injury ^[20]. The choice and timing of colloid is governed by these clinical anchors rather than by a fixed pediatric protocol.

Hypertonic saline¶

Hypertonic saline has a long history in pediatric burns and a contested evidence base. Caldwell and Bowser-Wallace's 1979 controlled trial alternately resuscitated children with thermal burns of 30% or more TBSA with hypertonic lactated saline or lactated Ringer's; although the hypertonic group received significantly more sodium than the Ringer's group, there was no difference in sodium balance at 48 hours post-burn ^[15]. Bowser-Wallace and Caldwell later reported that children resuscitated with hypertonic lactated saline required 23% less fluid in the first 24 hours, with significant differences between hypertonic and Ringer's-colloid arms in volume and weight gain ^[14]. A separate prospective Bowser-Wallace and Caldwell study compared hypertonic lactated saline against Ringer's lactate-colloid in children with burns of at least 30% TBSA; the hypertonic group required significantly less fluid at 24 hours (2.37 ± 0.91 vs 3.43 ± 1.51 mL/kg/%burn, p<0.01) and at 48 hours (4.18 ± 1.37 vs 6.32 mL/kg/%burn, p<0.01), while urine output and hematocrit did not differ between groups ^[59]. Belba et al. randomized 110 patients with severe burns to lactated Ringer's by Parkland (or Shriner for children) versus hypertonic resuscitation, and reported that hypertonic resuscitation consists of giving a higher fluid and sodium load in the first hour, accompanied by a decrease in fluid requirements and fluid accumulation for the first 24 hours of burn shock ^[16].

Enteral resuscitation¶

Enteral resuscitation is feasible in selected pediatric populations. Venter et al. randomized 18 children with less than 20% TBSA burns to early enteral feeding and resuscitation or intravenous resuscitation with delayed enteral feeding ^[5]. The enteral fluid volume was incrementally increased every 3 hours with a simultaneous equal reduction in the intravenous volume until all calculated intravenous fluid requirements for resuscitation and maintenance could be administered enterally ^[5]. Early enteral resuscitation and feeding was initiated within a median of 10.7 hours post-burn in nine children; the early-enteral group showed an anabolic response with significantly higher insulin concentrations (p=0.008) and insulin:glucagon ratios (p=0.043), and no pulmonary aspiration was found ^[5]. Diarrhoea in the early-enteral group settled within 2-4 days, whereas in the late-enteral-feeding group it persisted for longer than a week ^[5]. The late-enteral-feeding group lost a median of 7.75% of admission body weight, whereas the early-enteral group lost a median of 3.01%, and patients in the late group required antibiotic treatment for a longer period (p=0.08) and had a longer hospital stay ^[5]. Enteral resuscitation and early enteral feeding is a safe and effective method and particularly suited for children in developing countries ^[5]. Enteral resuscitation should not be introduced in a patient in shock or with existing gastrointestinal disease ^[5].

Hemodynamic-monitoring-guided titration¶

Hemodynamic monitoring beyond urine output has been studied in pediatric burns. Kraft et al. compared 76 severely burned pediatric patients with burns over 30% TBSA who received PiCCO-guided fluid resuscitation with 76 conventionally monitored patients; the PiCCO group received significantly less fluid (p<0.05) with similar urinary output, resulting in a significantly lower positive fluid balance (p<0.05) ^[4]. Central venous pressure in the PiCCO group was maintained in a more controlled range (p<0.05), associated with a significantly lower heart rate and significantly lower incidence of cardiac and renal failure (p<0.05) ^[4]. Fluid resuscitation guided by transcardiopulmonary thermodilution during hospitalization represents an effective adjunct and is associated with beneficial effects on post-burn morbidity in this pediatric cohort ^[4]. Recent evidence suggests that fluid calculation alone is inadequate and that over- and under-resuscitation are associated with increased morbidity and mortality ^[4]. The Sayın TTE study in 40 pediatric patients added echocardiographic-guided titration to standard endpoints and reduced diuretic use without changing mortality ^[12]. The PiCCO and TTE evidence anchors the broader observation that fluid calculation alone is inadequate and that over- and under-resuscitation are each associated with morbidity ^[4].

Time-to-surgery context¶

Pediatric resuscitation feeds into definitive surgical management. In the American Burn Association Burn Care Quality Platform analysis, 34.6% (7,247) of pediatric patients underwent surgery, with a median time to surgery of 1 day (interquartile range 1-3 days), compared with 49.3% (32,052) of adults and a median of 2 days ^[40]. Larger burns (≥20% TBSA) were treated slightly earlier, with median times of 1-3 days across groups ^[40]. Statistically significant differences were found in the pediatric 20-29% TBSA group (P=0.035) ^[40].

Complications¶

Pediatric resuscitation complications cluster at the over-resuscitation pole. In the Müller Dittrich cohort, fluid creep was observed in 13 controls (56.5%) and in one intervention patient (4.3%); significantly fewer cases of fluid creep and shorter hospital stay were observed in the early-albumin group ^[33]. Volume limit matters specifically for respiratory failure. Okabayashi et al. found a significant positive correlation between maximum respiratory index (AaDO2/PaO2) during the first week and the initial total volume administered (mL/kg per burn index) in massively burned children ^[27]. Fluid requirements to prevent post-resuscitation respiratory failure in massively burned children might be estimated according to the depth of burned area in addition to body weight and burn size ^[27]. A pediatric scald cohort showed that 4% required endotracheal intubation; intubated patients were younger (mean age 1.4 vs 2.8 years, p<0.001), had larger burns (29.9% vs 12.3% TBSA, p<0.001), and required more fluid resuscitation (7.66 vs 4.07 cc/kg/%TBSA, p<0.001) than non-intubated patients, with multivariate analysis identifying larger burn size (p=0.041) and younger age (p=0.049) as independent predictors of intubation ^[53]. The intubated patients had an average hourly urine output of 0.84 cc/kg during the first 24 hours, suggesting their resuscitation was not excessive ^[53]. Young patients with large body surface area burns requiring large resuscitation volumes are at risk for respiratory failure after a scald injury ^[53].

Multi-organ dysfunction is the late expression of inadequate resuscitation. Kraft et al. monitored multi-organ failure in 821 pediatric burn patients during acute hospitalization; respiratory failure had the highest incidence in the early phase of post-burn injury and decreased starting five days post-burn, cardiac failure had the highest incidence throughout hospital stay, hepatic failure increased with hospital length of stay and was associated with high mortality during the late phase, renal failure had an unexpectedly low incidence but was associated with high mortality during the first three weeks post-burn injury, and three or more organ failure was associated with very high mortality ^[23]. In a separate infant cohort, infection was suspected in 76 (13.5%) infants with positive blood cultures in 15 (20%) of the 76, ICU care was received in 46 (8.3%) infants, and ventilator-associated pneumonia was diagnosed in 8 (17%) of the ventilated children ^[49].

Toxic shock syndrome is a rare but life-threatening complication of pediatric burns. Gutzler et al. reviewed 59 cases observed in 10 countries; patient age ranged from 8 months to 8 years, injured TBSA ranged from less than 1% to 41%, and TSS diagnosis was made on day 5 after injury in median (range 3-34 days); awareness among treating clinicians is crucial for a favourable outcome ^[35].

Special Considerations¶

Infants and very young children¶

Children under three years and infants are the most resuscitation-sensitive subgroup. Bowser-Wallace and Caldwell found that children under three years required significantly more fluid and sodium during the first 48 hours when calculations were made using body weight as the indexing factor; when fluid and sodium needs were calculated using body surface area as the indexing factor, significant differences between age groups disappeared ^[14]. If body weight is used for estimating fluid needs, clinicians should be aware of the differences in fluid requirements for children less than or equal to 3 years old compared with older paediatric patients ^[14]. Fluid resuscitation after thermal injury in a child or infant can pose a set of unique and significant challenges ^[22]. Many pediatric patients with burn injuries may be initially treated in a hospital where pediatric specialized care, including resources and trained personnel, may be limited, and pediatric patients have different pharmacokinetics and pharmacodynamics affecting which medications are used and how they are dosed ^[21]. Resuscitation of the burned child should be modified based on the child's age, physiology, and response to injury ^[20].

Concomitant inhalation injury¶

Inhalation injury complicates fluid resuscitation in burned children. Navar et al. compared matched cohorts of patients with cutaneous burns alone and patients with concurrent inhalation injury and found that patients with inhalation injuries had a mean fluid requirement of 5.76 mL/kg per percent of total body surface area burned and a mean sodium requirement of 0.94 mEq/kg per percent of total body surface area burned, demonstrating that inhalation injury accompanying thermal trauma increases the magnitude of total body injury and requires increased volumes of fluid and sodium to achieve resuscitation from early burn shock ^[18]. Fluid administration of approximately 2 mL/kg per percent area burned above the calculated resuscitation volume is required following an inhalation injury to provide adequate support for the systemic circulation ^[19]. Nasotracheal intubation is preferred when airway integrity is compromised by inhalation injury ^[19]. In the infant cohort, ICU care was received in 46 (8.3%) infants and 15 (32.6%) of these had inhalation injuries; 11 (23.9%) of the inhalation injuries underwent mechanical ventilation for an average of 4.4 days ^[49].

Massive thermal injury¶

Children with very large burns require careful protocol-driven titration. Graves et al. studied 43 children ranging in age from 1.5 to 108 months with 25-89% TBSA burns and found that univariate and linear-regression analyses of age, weight, percentage full thickness, and inhalation injury revealed each had no significant influence on the volume of resuscitation; the average total volume of fluid received during the first 24 hours was 6.3 ± 2.2 cc/kg/%TBSA, with net resuscitation volume 3.91 ± 2.2 cc/kg/%TBSA after subtracting maintenance ^[13]. Shen et al. found that the ten-fold rehydration formula was 100% accurate at 30-55% TBSA and 88.28% at 56-85% TBSA but 0% at 86-100% TBSA; the same accuracy floor applied to the comparator TWGB formula ^[11]. Net fluid retention itself has been shown to track the extent of burn injury and to approximate the percentage body surface area burned when estimates come from a small, consistent clinical team in a single burn care system ^[60]. At the extreme high end of TBSA, individualized titration replaces formula-driven prediction.

Long-term growth¶

Children resuscitated through major burns show measurable growth perturbation in the first year. Cuijpers et al. reported that during the first-year post-burn, children's height and weight Z-scores decreased by 0.21 (95% CI 0.41, 0.01) and 0.23 (95% CI 0.46, 0.04) respectively; beyond the first year post-burn, estimates were consistent with a positive linear association between burn size and the overall effect of burns on height and weight Z-scores ^[42]. Children's height and weight Z-scores remained within the normal range throughout the study period, with children on track or even surpassing their growth potential ^[42].

Outcomes¶

Resuscitation timing is a strong outcome modifier in pediatric burns. Barrow et al. in a retrospective chart review of 133 children with scald or flame burns covering more than 50% of body surface area found that the incidence of sepsis, renal failure, non-survivors with cardiac arrest, and overall mortality was significantly higher in burned children receiving fluid resuscitation delayed by 2 hours or more, compared with those receiving fluid resuscitation within 2 hours of thermal injury (P<0.001) ^[3]. Fluid resuscitation, given within 2 hours of a thermal injury, may be one of the most important steps in the prevention of multi-organ failure and mortality ^[3].

Optimized fluid management has measurable outcome effects. The Kraft PiCCO-guided cohort had significantly lower heart rate, significantly lower incidence of cardiac and renal failure, and a significantly lower positive fluid balance compared with conventional management ^[4]. The Müller Dittrich early-albumin cohort had shorter hospital stay (14 vs 18 days, p=0.004) and dramatically less fluid creep (4.3% vs 56.5%) ^[33]. In Sayın et al.'s TTE-guided pediatric cohort, baseline group composition differed: the TTE group had higher initial intubation rates (55% vs 20%, p<0.05) and inotropic support (35% vs 5%, p<0.05). With those baseline differences accounted for, the TTE group required less diuretic treatment (10% vs 60%, p<0.05) without a significant mortality difference ^[12]. Long-term, children resuscitated through major burns are at risk for hypertrophic scarring and joint and soft tissue contractures, with factors associated with late complications including TBSA, burn depth, and limited infrastructure ^[36]. Among 991 children with long-term burn sequelae in a low- and middle-income systematic review, the time from injury to consultation ranged from a few months to 17 years ^[36].

Burn center volume independently lowers pediatric mortality. High-volume centers (admitting more than 200 pediatric patients per year) had the lowest mortality when adjusting for age and injury characteristics (p<0.05); an increase in median yearly admissions of 100 decreased the odds of mortality by approximately 40% ^[24]. Age, total body surface area burn, inhalation injury, and burn center volume each influenced mortality (p<0.05) ^[24]. A national time-to-surgery analysis of 99,195 patients reported median pediatric time to surgery of 1 day (IQR 1-3) and adult median 2 days (IQR 1-4) ^[40].

Readmission rates differ between children and adults. Tapking et al. in a systematic review and meta-analysis reported the overall readmission rate was 7.4% (95% CI 4.1-10.7) in adults and 2.7% (95% CI 2.2-3.2) in children; unplanned readmissions following burns are generally low and appear more common in adults than in pediatric patients ^[38].

Pediatric burn mortality has fallen over time. A Netherlands cohort showed an overall burn-centre mortality rate of 4.1%, significantly decreased over time ^[37]. Early fluid resuscitation within 2 hours of injury and early albumin in extensive burns each show measurable survival or length-of-stay benefits ^[3,33].

Controversies and Evidence Gaps¶

The pediatric fluid-resuscitation evidence base is thinner than the adult evidence base across several dimensions.

Urine output target. No randomized trial has compared different urine output targets in children with burns ^[2]. Targets in published pediatric studies range from 0.5-1.0 mL/kg/hour to 2-3 mL/kg/hour ^[2]. Heterogeneous study protocols and outcomes precluded comparison between the urine output targets in the most recent systematic review ^[2]. Even where urine output meets target, hemodynamic adequacy may not be assured: in 14 seriously burned patients with pulmonary arterial monitoring, vital signs and urine output changed little after fluid challenge while invasively derived physiologic variables demonstrated significant change, and in half of patients oxygen consumption increased after fluid challenge without distinction by vital signs or urine output ^[52]. Urinary output and vital signs alone may lead to suboptimal resuscitation, and invasive cardiorespiratory monitoring may be necessary to optimize resuscitation of seriously burned patients ^[52]. Few studies have researched resuscitation endpoints for children with burns, and there is a need for future randomised controlled trials to identify optimal endpoints with which to target fluid resuscitation in children with burns ^[2].

Formula choice. The optimal formula has not yet been identified across burn populations; multiple formulae produce strikingly diverse calculations of resuscitation fluid volumes, and only one historically published formula specifically dealt with fluid resuscitation in infants ^[9]. Variation in TBSA threshold for initiating resuscitation, Parkland coefficient, dextrose criteria, and urine output goal across five pediatric burn centers in the Pediatric Injury Quality Improvement Collaborative led to statistically significant differences in fluid estimates ^[10]. The Shen ten-fold formula performs well at moderate TBSA but reaches a 0% accuracy floor at burns greater than 85% TBSA ^[11].

Colloid timing. The Müller Dittrich trial established that early albumin (8-12 hours) versus delayed albumin (24 hours) in children with 15-45% TBSA burns reduces crystalloid requirements and length of stay; whether the same benefit extends to children with smaller or larger burns, or to alternative colloid products, is not directly addressed by the available pediatric evidence ^[33].

Hemodynamic monitoring. PiCCO-guided resuscitation reduced positive fluid balance and lowered cardiac and renal failure rates in a single-center pediatric cohort ^[4]. TTE-guided resuscitation reduced diuretic use without changing mortality in a small single-center pediatric cohort ^[12]. Multicenter pediatric RCTs of these monitoring strategies are absent.

Practice variation. Many approaches to fluid resuscitation of children after burns exist, and most are nonevidence based ^[22]. Practice variation across pediatric burn centers in formula coefficient, dextrose criteria, and urine output goal produces measurable differences in fluid estimates for comparable injuries ^[10]. One pediatric burn center modified its resuscitation guidelines at the conclusion of one such comparison ^[10].

Massive thermal injury accuracy. Formula accuracy falls to zero at burns greater than 85% TBSA in pediatric series ^[11]. For infants and children with massive thermal injury, maintenance volume is supplied alongside burn resuscitation initiated at 3 cc/kg/%TBSA ^[13].

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