This prospective randomized controlled trial compared 1:1 vs 4:1 packed red blood cell with fresh frozen plasma (PRBC/FFP) transfusion strategy on outcomes in children with >20% TBSA burns. Children with >20% TBSA burns were randomized to a 1:1 or 4:1 PRBC/FFP transfusion ratio during burn excision. Parameters measured included demographics, TBSA burn, and Pediatric Risk of Mortality scores. Laboratory values recorded preoperatively, 1 hour, 12 hours, 24 hours, and 1 week postoperatively included prothrombin time, partial thromboplastin time (PTT), international normalized ratio, fibrinogen, protein C, and antithrombin C (AIII). Total number of blood products transfused intraoperatively and during hospitalization was recorded. Forty-five children were enrolled, 22 in the 1:1 and 23 in the 4:1 group. Groups were similar in age, TBSA, and Pediatric Risk of Mortality score. Preoperative fibrinogen, AIII, protein C, hemoglobin, PTT, international normalized ratio, and platelets were similar. In the first two excisions, the 1:1 group received significantly more FFP per patient. Volume of PRBC and overall product transfused did not differ between groups. At 1 hour postoperatively, prothrombin time and PTT were lower and protein C and AIII were higher in the 1:1 group. The 4:1 group was more significantly acidotic 1 hour postexcision. A 1:1 PRBC/FFP transfusion strategy, compared with a 4:1 strategy, decreased postoperative markers of coagulopathy and acidosis immediately after surgery. The strategy did not change the total volume of blood product transfused. This interim analysis was not powered to detect differences in wound healing and length of stay.