A 3-day-old term neonate develops jaundice. Serum total bilirubin is 18 mg/dL (direct 0.4 mg/dL). Mother is O positive, baby is A positive. Direct Coombs test is weakly positive. The most appropriate immediate management is:

• A Commence intensive phototherapy ✓
• B Observe and repeat bilirubin in 24 hours
• C Perform exchange transfusion immediately
• D Start intravenous immunoglobulin without phototherapy

Explanation

ABO incompatibility (O mother, A or B baby) with a positive Coombs test causing indirect hyperbilirubinemia at 18 mg/dL on day 3 in a term neonate meets the threshold for intensive phototherapy per AAP 2004 guidelines (risk zone for term neonates ≥38 weeks). Exchange transfusion is reserved for bilirubin ≥25 mg/dL or if phototherapy fails. IVIG is adjunctive to phototherapy in isoimmune hemolytic disease when bilirubin approaches exchange threshold despite phototherapy, not as a standalone first-line measure.

Reference: Ghai Essential Pediatrics, 10th ed.

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