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This is VAERS ID 289543

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

VAERS ID: 289543
VAERS Form:
Age:0.2
Sex:Male
Location:California
Vaccinated:2007-08-09
Onset:2007-08-10
Submitted:2007-08-13
Entered:2007-08-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 0 RL / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 LL / UN
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B540138 / 0 LL / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1238F / 0 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Diet refusal, Endocardial fibroelastosis, Respiratory arrest, Congestive cardiomyopathy, Gaze palsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Nystatin suspension
Current Illness: thrush, oral
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.


Changed on 12/8/2009

VAERS ID: 289543 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:California
Vaccinated:2007-08-09
Onset:2007-08-10
Submitted:2007-08-13
Entered:2007-08-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 0 RL / UN
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 0 RL / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 LL / UN
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B540138 / 0 LL / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1238F / 0 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Diet refusal, Endocardial fibroelastosis, Respiratory arrest, Resuscitation, Sudden infant death syndrome, Congestive cardiomyopathy, Gaze palsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 3/2/2010

VAERS ID: 289543 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:California
Vaccinated:2007-08-09
Onset:2007-08-10
Submitted:2007-08-13
Entered:2007-08-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 0 RL / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 LL / UN
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC B540138 / 0 LL / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1238F / 0 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Diet refusal, Endocardial fibroelastosis, Respiratory arrest, Resuscitation, Sudden infant death syndrome, Congestive cardiomyopathy, Gaze palsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 4/7/2010

VAERS ID: 289543 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:California
Vaccinated:2007-08-09
Onset:2007-08-10
Submitted:2007-08-13
Entered:2007-08-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 0 RL / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 LL / UN
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B540138 / 0 LL / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1238F / 0 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Diet refusal, Endocardial fibroelastosis, Respiratory arrest, Resuscitation, Sudden infant death syndrome, Congestive cardiomyopathy, Gaze palsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 8/31/2010

VAERS ID: 289543 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:California
Vaccinated:2007-08-09
Onset:2007-08-10
Submitted:2007-08-13
Entered:2007-08-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 0 RL / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 LL / UN
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH B540138 / 0 LL / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1238F / 0 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Diet refusal, Endocardial fibroelastosis, Respiratory arrest, Resuscitation, Sudden infant death syndrome, Congestive cardiomyopathy, Gaze palsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 5/13/2013

VAERS ID: 289543 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:California
Vaccinated:2007-08-09
Onset:2007-08-10
Submitted:2007-08-13
Entered:2007-08-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 0 RL / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B540138 / 0 LL / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1238F / 0 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1238F / 0 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Diet refusal, Endocardial fibroelastosis, Respiratory arrest, Resuscitation, Sudden infant death syndrome, Congestive cardiomyopathy, Gaze palsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 5/14/2017

VAERS ID: 289543 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:California
Vaccinated:2007-08-09
Onset:2007-08-10
Submitted:2007-08-13
Entered:2007-08-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 0 RL / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B540138 / 0 LL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1238F / 0 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Diet refusal, Endocardial fibroelastosis, Respiratory arrest, Resuscitation, Sudden infant death syndrome, Congestive cardiomyopathy, Gaze palsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 9/14/2017

VAERS ID: 289543 Before After
VAERS Form:(blank) 1
Age:0.2
Sex:Male
Location:California
Vaccinated:2007-08-09
Onset:2007-08-10
Submitted:2007-08-13
Entered:2007-08-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 0 1 RL / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 1 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B540138 / 0 1 LL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1238F / 0 1 - MO / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Diet refusal, Respiratory arrest, Resuscitation, Gaze palsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 2/14/2018

VAERS ID: 289543 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:California
Vaccinated:2007-08-09
Onset:2007-08-10
Submitted:2007-08-13
Entered:2007-08-31
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, Respiratory arrest, Resuscitation, Gaze palsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 6/14/2018

VAERS ID: 289543 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:California
Vaccinated:2007-08-09
Onset:2007-08-10
Submitted:2007-08-13
Entered:2007-08-31
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, Respiratory arrest, Resuscitation, Gaze palsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 8/14/2018

VAERS ID: 289543 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:California
Vaccinated:2007-08-09
Onset:2007-08-10
Submitted:2007-08-13
Entered:2007-08-31
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, Respiratory arrest, Resuscitation, Gaze palsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 9/14/2018

VAERS ID: 289543 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:California
Vaccinated:2007-08-09
Onset:2007-08-10
Submitted:2007-08-13
Entered:2007-08-31
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, Respiratory arrest, Resuscitation, Gaze palsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 10/14/2018

VAERS ID: 289543 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:California
Vaccinated:2007-08-09
Onset:2007-08-10
Submitted:2007-08-13
Entered:2007-08-31
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, Respiratory arrest, Resuscitation, Gaze palsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 12/24/2020

VAERS ID: 289543 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:California
Vaccinated:2007-08-09
Onset:2007-08-10
Submitted:2007-08-13
Entered:2007-08-31
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, Respiratory arrest, Resuscitation, Gaze palsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 12/30/2020

VAERS ID: 289543 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:California
Vaccinated:2007-08-09
Onset:2007-08-10
Submitted:2007-08-13
Entered:2007-08-31
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, Respiratory arrest, Resuscitation, Gaze palsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 5/7/2021

VAERS ID: 289543 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:California
Vaccinated:2007-08-09
Onset:2007-08-10
Submitted:2007-08-13
Entered:2007-08-31
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, Respiratory arrest, Resuscitation, Gaze palsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 5/14/2021

VAERS ID: 289543 Before After
VAERS Form:1
Age:0.2
Sex:Male
Location:California
Vaccinated:2007-08-09
Onset:2007-08-10
Submitted:2007-08-13
Entered:2007-08-31
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, Respiratory arrest, Resuscitation, Gaze palsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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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