what is the cause of anaemia in this case!!!

[alzahra]

Three months male baby from Yemen complianing of pallor since first month. Condition was started since birth when the baby developed jaundice at 1st day. (He was full term, normal vaginal delivery).
Investigation at 1st day:
• His Blood group  O-ve – Mother’s B-G O+ve
• Bilirubin was 23,5 mg/dl – direct 2,03 mg/dl
• Reticulocyes 20%
• Hb = 9,7 Bilirubin not respond to phototherapy so Blood exchange was done after it HB was 11,3 g/dl  After that he was on phototherapy,:
• Hb = 13,8  -Platelet = 63  
  Blood Film:
• RBc   normocytic  normchromic with some marocytes of few nucleated cells no specific abnormalities .
• WBc Normal count, Normal Morphology.
• PLTs  Low count with Normal Morphology.
Platelet transfusion was done and it became = 185 AND continued on phototherapy.
He discharged after 7 days with total bilirubin 10,20 mg/dl – direct 1,1 T. bilirubin repeated after 1 WK  1 mg/dl.
Patient is well active, normal breast feeding in addition he get artificial milk.
He was ok until he was two months when his mother noted that he was pale -  

Hb = 5 g/dl
• Wbc = 9,4
• PLT = 213
• MCV = 89
• MCH= 28
• McHc= 32
• RDW = 23,4
Blood Film report:
RBC  Normocytic Normochromic with some polychromatic and few spherocytes fragmented and nucleated cells.
WBC  Normal
• Bilirubin = 2
• LDH = 3244
• Direct combs test –ve
• G6PD = 243 (Normal 60-130)
• Osmotic fragility test –ve
• Electrophoresis Normal
• Fe = Normal – Ferrtin = high
Transfusion of 80 cc packed RBc was done (he was 5 kg).
One month later, patient became pale again with Hb 7 g/dl retics = 3.2 and other 80 cc were given.
• By examination of patient there’s only spleenomegaly that confirmed by ultrasound + He was pale.
Chest is clear, Normal heart sound
• No change in urin color
B.W = 5,5 kg
What is the possible cause?!!!
What other investigation is needed?  
what is  the haemoglobin level for blood transfusion?

[alzahra]

thank you for your response but we have not pediatric hematologist and I try to found one on net to advice me what other things can I do .

[Yao Sun, MD, PhD]

The baby as had an extensive workup for the most common causes of anemia.  Although the high LDH level might still be a sign of red blood cell breakdown (hemolysis), the most common causes of hemolysis have been tested and none of the tests are positive.

If it hasn't already been done, the baby deserves a referral to a pediatric hematologist.  They are the specialists who can manage the further evaluation of this anemia, since the underlying cause is not one of the most frequent ones.  They can also review the blood smears for any further clues.