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We are dealing with a 24 day old baby who just had his second top up transfusion. He was born at term to an A neg mom who was discovered at that time to have anti-D. Her titer was 32. She had a negative antibody screen at the beginning of the pregnancy but was not tested when she got her 28 week dose of RhIG. The baby was A pos and had a strongly pos DAT. These results triggered us to test the mom and find the anti-D (we don't do routine screens on all OB admits). The baby had a Hct at birth of 40, so a bit low but not worrisome. He was under bili lights for 5 days and went home with a bili of about 9 and was under home bili lights also. Peak bili was 15. Over this time, his Hct slowly drifted downward. It was 30.7 when he was discharged at 5 days old. He was followed as an OP for bili and H&H. He had to come in for a transfusion (his first) when he was 11 days old because his Hct was down to 17. The morning after that transfusion his Hct was 27. Now some two weeks later he had to come back in for another transfusion because his Hct on Saturday was 20.4 and he was acting tired--feeding taking a long time. His retic count is elevated although not as high as it was before the first transfusion. His LDH is normal. His bili is still a bit high at 3.3 but he does not appear jaundiced. His direct bili is normal. After the latest transfusion, they have him up to Hct 26.5 and sent him home again. He still has a pos DAT(although weaker than before) and has anti-D in his plasma. He has gained weight and is developing normally. The MD doesn't think he is losing blood (other than being sampled every 2-3 days for testing). We transfused O negative blood both times from the same donor. Baby has not had any viruses and seems otherwise well. If anyone has ever seen such a case, please let me know what the cause was determined to be. Or I will take our usual wild speculation and ideas of things to look for. There is an idea from the doctor of autoimmune hemolytic anemia. We have not done an eluate on his most recent specimen--there probably aren't many red cells left to test. I would think his bili and his LDH would be higher in AIHA.