A term neonate develops severe unconjugated hyperbilirubinemia (total bilirubin 28 mg/dL) at 36 hours of life. Blood group is O Rh-positive mother, A Rh-positive infant. DAT (Coombs test) is positive. The infant is developing hypotonia. What is the MOST appropriate urgent intervention?
- A Intensive phototherapy with double-surface LED for 24 hours and recheck
- B Double volume exchange transfusion (DVET) immediately given the bilirubin level and neurological signs ✓
- C IV immunoglobulin 0.5–1 g/kg administered within 24 hours and phototherapy
- D Discontinue breastfeeding and replace with formula for 48 hours
Explanation
Double-volume exchange transfusion (DVET) is indicated when total serum bilirubin reaches exchange transfusion thresholds on the Bhutani nomogram OR when there are signs of acute bilirubin encephalopathy (ABE) — hypotonia, poor suck, fever, arching, high-pitched cry — regardless of bilirubin level. At 28 mg/dL (well above exchange threshold for term infants) with neurological signs (hypotonia), DVET is urgently required. IVIG reduces hemolysis in isoimmune hemolytic disease but is an adjunct — it should not delay exchange transfusion when neurological signs are present. Phototherapy alone is inadequate at this level with encephalopathy.
Reference: Ghai Essential Pediatrics, 10th ed.
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Written and medically reviewed by the StethoPrep medical team.