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From the 9/17/2021 release of VAERS data:

This is VAERS ID 289543



Case Details

VAERS ID: 289543 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: California  
Vaccinated:2007-08-09
Onset:2007-08-10
   Days after vaccination:1
Submitted: 2007-08-13
   Days after onset:3
Entered: 2007-08-31
   Days after submission:18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 1 RL / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 1 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B540138 / 1 LL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1238F / 1 MO / PO

Administered by: Private       Purchased by: Unknown
Symptoms: Diet refusal, Gaze palsy, Respiratory arrest, Resuscitation
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Ocular motility disorders (narrow), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2007-08-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Nystatin suspension
Current Illness: thrush, oral umbilical hernia
Preexisting Conditions: sickle-cell trait
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Per ER call to on call physician 8/11. Last night he stopped feeding and then his eyes rolled back and he stopped breathing. 911 called and CPR initiated. Coded for 1-1/2 hours (paramedics and ER) without success. 9/4/07 Received pcp medical records which included vax record which confirmed RO dose & lot #s as reported. Office note of 8/9 indicates well child visit on day of vax excep for thrush & umbilical hernia. 1/8/08 Reviewed autopsy report which states COD as sudden unexplained infant death syndrome due to dilated cardiomyopathy & primary endocardial fibroelastosis, dilated form.


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