National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 420337

Government Disclaimer on use of this data

History of Changes from the VAERS Wayback Machine

First Appeared on 4/13/2011

VAERS ID: 420337
VAERS Form:
Age:0.2
Sex:Male
Location:Florida
Vaccinated:2011-03-30
Onset:2011-03-31
Submitted:2011-04-05
Entered:2011-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B256CA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH254AA / 0 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1074Z / 0 - / PO

Administered by: Public      Purchased by: Public
Symptoms: Cold sweat, Death, Hypotonia, Respiratory arrest, Skin warm, Somnolence, Yellow skin, Hypophagia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-31
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: none
Current Illness: well baby
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 4-1-2011 mother presents to clinic requesting child, immunization record. Mother reports that her baby died 3-31-2011 at approximately 10:50 am. She reports the following: On 3-30-11 at 12:30pm she brought patient to the CHD for a routine well baby visit and immunizations. The child was done with the visit and receiving his shots by about 1pm. The rest of the day the child was sleepy and ate about 2 oz of formula vs his normal 7 oz at a time. At 11:30 pm she performed his routine diaper change and feeding. At that time he was moist to touch, but not running a fever (she never took his temperature but he felt warm to touch). 3-31-11 2AM; the baby accompanied the family to the ER for another child''s scraped knee. They returned at 4AM, in which the mother reports she fed the baby 2 oz and did a diaper change. 10:40 AM the mother woke up and checked the baby, the baby was sleeping on his stomach. She reports that she does not believe in putting the baby on his back, because she thinks the baby will choke, she admits that she was trained by the provider, he should be on his back for sleeping. She then went out to the garage to have a cigarette. She returned at 10:50 am to get the baby up. The babies arm was flopped out and looked yellow, she checked the baby for breathing, and he was not breathing, then called 911. I gave the mother a copy of the child''s immunization record. Offered Healthy Start bereavement services, she declined, stating she has enough family support for that.


Changed on 5/13/2013

VAERS ID: 420337 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Florida
Vaccinated:2011-03-30
Onset:2011-03-31
Submitted:2011-04-05
Entered:2011-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B256CA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH254AA / 0 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1074Z / 0 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1074Z / 0 - / PO

Administered by: Public      Purchased by: Public
Symptoms: Cold sweat, Death, Hypotonia, Respiratory arrest, Skin warm, Somnolence, Yellow skin, Hypophagia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-31
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: none
Current Illness: well baby
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 4-1-2011 mother presents to clinic requesting child, immunization record. Mother reports that her baby died 3-31-2011 at approximately 10:50 am. She reports the following: On 3-30-11 at 12:30pm she brought patient to the CHD for a routine well baby visit and immunizations. The child was done with the visit and receiving his shots by about 1pm. The rest of the day the child was sleepy and ate about 2 oz of formula vs his normal 7 oz at a time. At 11:30 pm she performed his routine diaper change and feeding. At that time he was moist to touch, but not running a fever (she never took his temperature but he felt warm to touch). 3-31-11 2AM; the baby accompanied the family to the ER for another child''s scraped knee. They returned at 4AM, in which the mother reports she fed the baby 2 oz and did a diaper change. 10:40 AM the mother woke up and checked the baby, the baby was sleeping on his stomach. She reports that she does not believe in putting the baby on his back, because she thinks the baby will choke, she admits that she was trained by the provider, he should be on his back for sleeping. She then went out to the garage to have a cigarette. She returned at 10:50 am to get the baby up. The babies arm was flopped out and looked yellow, she checked the baby for breathing, and he was not breathing, then called 911. I gave the mother a copy of the child''s immunization record. Offered Healthy Start bereavement services, she declined, stating she has enough family support for that.


Changed on 6/14/2014

VAERS ID: 420337 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Florida
Vaccinated:2011-03-30
Onset:2011-03-31
Submitted:2011-04-05
Entered:2011-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B256CA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH254AA / 0 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 0 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1074Z / 0 - / PO

Administered by: Public      Purchased by: Public
Symptoms: Cold sweat, Death, Hypotonia, Respiratory arrest, Skin warm, Somnolence, Yellow skin, Hypophagia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-31
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: none
Current Illness: well baby
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 4-1-2011 mother presents to clinic requesting child, immunization record. Mother reports that her baby died 3-31-2011 at approximately 10:50 am. She reports the following: On 3-30-11 at 12:30pm she brought patient to the CHD for a routine well baby visit and immunizations. The child was done with the visit and receiving his shots by about 1pm. The rest of the day the child was sleepy and ate about 2 oz of formula vs his normal 7 oz at a time. At 11:30 pm she performed his routine diaper change and feeding. At that time he was moist to touch, but not running a fever (she never took his temperature but he felt warm to touch). 3-31-11 2AM; the baby accompanied the family to the ER for another child''s scraped knee. They returned at 4AM, in which the mother reports she fed the baby 2 oz and did a diaper change. 10:40 AM the mother woke up and checked the baby, the baby was sleeping on his stomach. She reports that she does not believe in putting the baby on his back, because she thinks the baby will choke, she admits that she was trained by the provider, he should be on his back for sleeping. She then went out to the garage to have a cigarette. She returned at 10:50 am to get the baby up. The babies arm was flopped out and looked yellow, she checked the baby for breathing, and he was not breathing, then called 911. I gave the mother a copy of the child''s immunization record. Offered Healthy Start bereavement services, she declined, stating she has enough family support for that.


Changed on 2/14/2017

VAERS ID: 420337 Before After
VAERS Form:
Age:0.2 0.18
Sex:Male
Location:Florida
Vaccinated:2011-03-30
Onset:2011-03-31
Submitted:2011-04-05
Entered:2011-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B256CA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH254AA / 0 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 0 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1074Z / 0 - / PO

Administered by: Public      Purchased by: Public
Symptoms: Cold sweat, Death, Hypotonia, Respiratory arrest, Skin warm, Somnolence, Yellow skin, Hypophagia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-31
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:
Current Illness: well baby
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 4-1-2011 mother presents to clinic requesting child, immunization record. Mother reports that her baby died 3-31-2011 at approximately 10:50 am. She reports the following: On 3-30-11 at 12:30pm she brought patient to the CHD for a routine well baby visit and immunizations. The child was done with the visit and receiving his shots by about 1pm. The rest of the day the child was sleepy and ate about 2 oz of formula vs his normal 7 oz at a time. At 11:30 pm she performed his routine diaper change and feeding. At that time he was moist to touch, but not running a fever (she never took his temperature but he felt warm to touch). 3-31-11 2AM; the baby accompanied the family to the ER for another child''s scraped knee. They returned at 4AM, in which the mother reports she fed the baby 2 oz and did a diaper change. 10:40 AM the mother woke up and checked the baby, the baby was sleeping on his stomach. She reports that she does not believe in putting the baby on his back, because she thinks the baby will choke, she admits that she was trained by the provider, he should be on his back for sleeping. She then went out to the garage to have a cigarette. She returned at 10:50 am to get the baby up. The babies arm was flopped out and looked yellow, she checked the baby for breathing, and he was not breathing, then called 911. I gave the mother a copy of the child''s immunization record. Offered Healthy Start bereavement services, she declined, stating she has enough family support for that.


Changed on 4/14/2017

VAERS ID: 420337 Before After
VAERS Form:
Age:0.18
Sex:Male
Location:Florida
Vaccinated:2011-03-30
Onset:2011-03-31
Submitted:2011-04-05
Entered:2011-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B256CA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH254AA / 0 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 0 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1074Z / 0 - / PO

Administered by: Public      Purchased by: Public
Symptoms: Cold sweat, Death, Hypotonia, Respiratory arrest, Skin warm, Somnolence, Yellow skin, Hypophagia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-31
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: none
Current Illness: well baby
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 4-1-2011 mother presents to clinic requesting child, immunization record. Mother reports that her baby died 3-31-2011 at approximately 10:50 am. She reports the following: On 3-30-11 at 12:30pm she brought patient to the CHD for a routine well baby visit and immunizations. The child was done with the visit and receiving his shots by about 1pm. The rest of the day the child was sleepy and ate about 2 oz of formula vs his normal 7 oz at a time. At 11:30 pm she performed his routine diaper change and feeding. At that time he was moist to touch, but not running a fever (she never took his temperature but he felt warm to touch). 3-31-11 2AM; the baby accompanied the family to the ER for another child''s scraped knee. They returned at 4AM, in which the mother reports she fed the baby 2 oz and did a diaper change. 10:40 AM the mother woke up and checked the baby, the baby was sleeping on his stomach. She reports that she does not believe in putting the baby on his back, because she thinks the baby will choke, she admits that she was trained by the provider, he should be on his back for sleeping. She then went out to the garage to have a cigarette. She returned at 10:50 am to get the baby up. The babies arm was flopped out and looked yellow, she checked the baby for breathing, and he was not breathing, then called 911. I gave the mother a copy of the child''s immunization record. Offered Healthy Start bereavement services, she declined, stating she has enough family support for that.


Changed on 9/14/2017

VAERS ID: 420337 Before After
VAERS Form:(blank) 1
Age:0.18
Sex:Male
Location:Florida
Vaccinated:2011-03-30
Onset:2011-03-31
Submitted:2011-04-05
Entered:2011-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B256CA / 0 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH254AA / 0 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 0 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1074Z / 0 1 - MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Cold sweat, Death, Hypotonia, Respiratory arrest, Skin warm, Somnolence, Yellow skin, Hypophagia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-31
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: none
Current Illness: well baby
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 4-1-2011 mother presents to clinic requesting child, immunization record. Mother reports that her baby died 3-31-2011 at approximately 10:50 am. She reports the following: On 3-30-11 at 12:30pm she brought patient to the CHD for a routine well baby visit and immunizations. The child was done with the visit and receiving his shots by about 1pm. The rest of the day the child was sleepy and ate about 2 oz of formula vs his normal 7 oz at a time. At 11:30 pm she performed his routine diaper change and feeding. At that time he was moist to touch, but not running a fever (she never took his temperature but he felt warm to touch). 3-31-11 2AM; the baby accompanied the family to the ER for another child''s scraped knee. They returned at 4AM, in which the mother reports she fed the baby 2 oz and did a diaper change. 10:40 AM the mother woke up and checked the baby, the baby was sleeping on his stomach. She reports that she does not believe in putting the baby on his back, because she thinks the baby will choke, she admits that she was trained by the provider, he should be on his back for sleeping. She then went out to the garage to have a cigarette. She returned at 10:50 am to get the baby up. The babies arm was flopped out and looked yellow, she checked the baby for breathing, and he was not breathing, then called 911. I gave the mother a copy of the child''s immunization record. Offered Healthy Start bereavement services, she declined, stating she has enough family support for that.


Changed on 2/14/2018

VAERS ID: 420337 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Florida
Vaccinated:2011-03-30
Onset:2011-03-31
Submitted:2011-04-05
Entered:2011-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B256CA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH254AA / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1074Z / 1 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Cold sweat, Death, Hypotonia, Respiratory arrest, Skin warm, Somnolence, Yellow skin, Hypophagia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-31
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: none
Current Illness: well baby
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 4-1-2011 mother presents to clinic requesting child, immunization record. Mother reports that her baby died 3-31-2011 at approximately 10:50 am. She reports the following: On 3-30-11 at 12:30pm she brought patient to the CHD for a routine well baby visit and immunizations. The child was done with the visit and receiving his shots by about 1pm. The rest of the day the child was sleepy and ate about 2 oz of formula vs his normal 7 oz at a time. At 11:30 pm she performed his routine diaper change and feeding. At that time he was moist to touch, but not running a fever (she never took his temperature but he felt warm to touch). 3-31-11 2AM; the baby accompanied the family to the ER for another child''s scraped knee. They returned at 4AM, in which the mother reports she fed the baby 2 oz and did a diaper change. 10:40 AM the mother woke up and checked the baby, the baby was sleeping on his stomach. She reports that she does not believe in putting the baby on his back, because she thinks the baby will choke, she admits that she was trained by the provider, he should be on his back for sleeping. She then went out to the garage to have a cigarette. She returned at 10:50 am to get the baby up. The babies arm was flopped out and looked yellow, she checked the baby for breathing, and he was not breathing, then called 911. I gave the mother a copy of the child''s immunization record. Offered Healthy Start bereavement services, she declined, stating she has enough family support for that.


Changed on 6/14/2018

VAERS ID: 420337 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Florida
Vaccinated:2011-03-30
Onset:2011-03-31
Submitted:2011-04-05
Entered:2011-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B256CA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH254AA / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1074Z / 1 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Cold sweat, Death, Hypotonia, Respiratory arrest, Skin warm, Somnolence, Yellow skin, Hypophagia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-31
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: none
Current Illness: well baby
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 4-1-2011 mother presents to clinic requesting child, immunization record. Mother reports that her baby died 3-31-2011 at approximately 10:50 am. She reports the following: On 3-30-11 at 12:30pm she brought patient to the CHD for a routine well baby visit and immunizations. The child was done with the visit and receiving his shots by about 1pm. The rest of the day the child was sleepy and ate about 2 oz of formula vs his normal 7 oz at a time. At 11:30 pm she performed his routine diaper change and feeding. At that time he was moist to touch, but not running a fever (she never took his temperature but he felt warm to touch). 3-31-11 2AM; the baby accompanied the family to the ER for another child''s scraped knee. They returned at 4AM, in which the mother reports she fed the baby 2 oz and did a diaper change. 10:40 AM the mother woke up and checked the baby, the baby was sleeping on his stomach. She reports that she does not believe in putting the baby on his back, because she thinks the baby will choke, she admits that she was trained by the provider, he should be on his back for sleeping. She then went out to the garage to have a cigarette. She returned at 10:50 am to get the baby up. The babies arm was flopped out and looked yellow, she checked the baby for breathing, and he was not breathing, then called 911. I gave the mother a copy of the child''s immunization record. Offered Healthy Start bereavement services, she declined, stating she has enough family support for that.


Changed on 8/14/2018

VAERS ID: 420337 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Florida
Vaccinated:2011-03-30
Onset:2011-03-31
Submitted:2011-04-05
Entered:2011-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B256CA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH254AA / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1074Z / 1 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Cold sweat, Death, Hypotonia, Respiratory arrest, Skin warm, Somnolence, Yellow skin, Hypophagia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-31
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: none
Current Illness: well baby
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 4-1-2011 mother presents to clinic requesting child, immunization record. Mother reports that her baby died 3-31-2011 at approximately 10:50 am. She reports the following: On 3-30-11 at 12:30pm she brought patient to the CHD for a routine well baby visit and immunizations. The child was done with the visit and receiving his shots by about 1pm. The rest of the day the child was sleepy and ate about 2 oz of formula vs his normal 7 oz at a time. At 11:30 pm she performed his routine diaper change and feeding. At that time he was moist to touch, but not running a fever (she never took his temperature but he felt warm to touch). 3-31-11 2AM; the baby accompanied the family to the ER for another child''s scraped knee. They returned at 4AM, in which the mother reports she fed the baby 2 oz and did a diaper change. 10:40 AM the mother woke up and checked the baby, the baby was sleeping on his stomach. She reports that she does not believe in putting the baby on his back, because she thinks the baby will choke, she admits that she was trained by the provider, he should be on his back for sleeping. She then went out to the garage to have a cigarette. She returned at 10:50 am to get the baby up. The babies arm was flopped out and looked yellow, she checked the baby for breathing, and he was not breathing, then called 911. I gave the mother a copy of the child''s immunization record. Offered Healthy Start bereavement services, she declined, stating she has enough family support for that.


Changed on 9/14/2018

VAERS ID: 420337 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Florida
Vaccinated:2011-03-30
Onset:2011-03-31
Submitted:2011-04-05
Entered:2011-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B256CA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH254AA / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1074Z / 1 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Cold sweat, Death, Hypotonia, Respiratory arrest, Skin warm, Somnolence, Yellow skin, Hypophagia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-31
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: none
Current Illness: well baby
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 4-1-2011 mother presents to clinic requesting child, immunization record. Mother reports that her baby died 3-31-2011 at approximately 10:50 am. She reports the following: On 3-30-11 at 12:30pm she brought patient to the CHD for a routine well baby visit and immunizations. The child was done with the visit and receiving his shots by about 1pm. The rest of the day the child was sleepy and ate about 2 oz of formula vs his normal 7 oz at a time. At 11:30 pm she performed his routine diaper change and feeding. At that time he was moist to touch, but not running a fever (she never took his temperature but he felt warm to touch). 3-31-11 2AM; the baby accompanied the family to the ER for another child''s scraped knee. They returned at 4AM, in which the mother reports she fed the baby 2 oz and did a diaper change. 10:40 AM the mother woke up and checked the baby, the baby was sleeping on his stomach. She reports that she does not believe in putting the baby on his back, because she thinks the baby will choke, she admits that she was trained by the provider, he should be on his back for sleeping. She then went out to the garage to have a cigarette. She returned at 10:50 am to get the baby up. The babies arm was flopped out and looked yellow, she checked the baby for breathing, and he was not breathing, then called 911. I gave the mother a copy of the child''s immunization record. Offered Healthy Start bereavement services, she declined, stating she has enough family support for that.


Changed on 10/14/2018

VAERS ID: 420337 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Florida
Vaccinated:2011-03-30
Onset:2011-03-31
Submitted:2011-04-05
Entered:2011-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B256CA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH254AA / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1074Z / 1 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Cold sweat, Death, Hypotonia, Respiratory arrest, Skin warm, Somnolence, Yellow skin, Hypophagia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-31
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: none
Current Illness: well baby
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 4-1-2011 mother presents to clinic requesting child, immunization record. Mother reports that her baby died 3-31-2011 at approximately 10:50 am. She reports the following: On 3-30-11 at 12:30pm she brought patient to the CHD for a routine well baby visit and immunizations. The child was done with the visit and receiving his shots by about 1pm. The rest of the day the child was sleepy and ate about 2 oz of formula vs his normal 7 oz at a time. At 11:30 pm she performed his routine diaper change and feeding. At that time he was moist to touch, but not running a fever (she never took his temperature but he felt warm to touch). 3-31-11 2AM; the baby accompanied the family to the ER for another child''s scraped knee. They returned at 4AM, in which the mother reports she fed the baby 2 oz and did a diaper change. 10:40 AM the mother woke up and checked the baby, the baby was sleeping on his stomach. She reports that she does not believe in putting the baby on his back, because she thinks the baby will choke, she admits that she was trained by the provider, he should be on his back for sleeping. She then went out to the garage to have a cigarette. She returned at 10:50 am to get the baby up. The babies arm was flopped out and looked yellow, she checked the baby for breathing, and he was not breathing, then called 911. I gave the mother a copy of the child''s immunization record. Offered Healthy Start bereavement services, she declined, stating she has enough family support for that.


Changed on 12/24/2020

VAERS ID: 420337 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Florida
Vaccinated:2011-03-30
Onset:2011-03-31
Submitted:2011-04-05
Entered:2011-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B256CA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH254AA / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1074Z / 1 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Cold sweat, Death, Hypotonia, Respiratory arrest, Skin warm, Somnolence, Yellow skin, Hypophagia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-31
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: none
Current Illness: well baby
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 4-1-2011 mother presents to clinic requesting child, immunization record. Mother reports that her baby died 3-31-2011 at approximately 10:50 am. She reports the following: On 3-30-11 at 12:30pm she brought patient to the CHD for a routine well baby visit and immunizations. The child was done with the visit and receiving his shots by about 1pm. The rest of the day the child was sleepy and ate about 2 oz of formula vs his normal 7 oz at a time. At 11:30 pm she performed his routine diaper change and feeding. At that time he was moist to touch, but not running a fever (she never took his temperature but he felt warm to touch). 3-31-11 2AM; the baby accompanied the family to the ER for another child''s scraped knee. They returned at 4AM, in which the mother reports she fed the baby 2 oz and did a diaper change. 10:40 AM the mother woke up and checked the baby, the baby was sleeping on his stomach. She reports that she does not believe in putting the baby on his back, because she thinks the baby will choke, she admits that she was trained by the provider, he should be on his back for sleeping. She then went out to the garage to have a cigarette. She returned at 10:50 am to get the baby up. The babies arm was flopped out and looked yellow, she checked the baby for breathing, and he was not breathing, then called 911. I gave the mother a copy of the child''s immunization record. Offered Healthy Start bereavement services, she declined, stating she has enough family support for that.


Changed on 12/30/2020

VAERS ID: 420337 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Florida
Vaccinated:2011-03-30
Onset:2011-03-31
Submitted:2011-04-05
Entered:2011-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B256CA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH254AA / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1074Z / 1 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Cold sweat, Death, Hypotonia, Respiratory arrest, Skin warm, Somnolence, Yellow skin, Hypophagia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-31
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: none
Current Illness: well baby
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 4-1-2011 mother presents to clinic requesting child, immunization record. Mother reports that her baby died 3-31-2011 at approximately 10:50 am. She reports the following: On 3-30-11 at 12:30pm she brought patient to the CHD for a routine well baby visit and immunizations. The child was done with the visit and receiving his shots by about 1pm. The rest of the day the child was sleepy and ate about 2 oz of formula vs his normal 7 oz at a time. At 11:30 pm she performed his routine diaper change and feeding. At that time he was moist to touch, but not running a fever (she never took his temperature but he felt warm to touch). 3-31-11 2AM; the baby accompanied the family to the ER for another child''s scraped knee. They returned at 4AM, in which the mother reports she fed the baby 2 oz and did a diaper change. 10:40 AM the mother woke up and checked the baby, the baby was sleeping on his stomach. She reports that she does not believe in putting the baby on his back, because she thinks the baby will choke, she admits that she was trained by the provider, he should be on his back for sleeping. She then went out to the garage to have a cigarette. She returned at 10:50 am to get the baby up. The babies arm was flopped out and looked yellow, she checked the baby for breathing, and he was not breathing, then called 911. I gave the mother a copy of the child''s immunization record. Offered Healthy Start bereavement services, she declined, stating she has enough family support for that.


Changed on 5/7/2021

VAERS ID: 420337 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Florida
Vaccinated:2011-03-30
Onset:2011-03-31
Submitted:2011-04-05
Entered:2011-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B256CA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH254AA / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1074Z / 1 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Cold sweat, Death, Hypotonia, Respiratory arrest, Skin warm, Somnolence, Yellow skin, Hypophagia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-31
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: none
Current Illness: well baby
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 4-1-2011 mother presents to clinic requesting child, immunization record. Mother reports that her baby died 3-31-2011 at approximately 10:50 am. She reports the following: On 3-30-11 at 12:30pm she brought patient to the CHD for a routine well baby visit and immunizations. The child was done with the visit and receiving his shots by about 1pm. The rest of the day the child was sleepy and ate about 2 oz of formula vs his normal 7 oz at a time. At 11:30 pm she performed his routine diaper change and feeding. At that time he was moist to touch, but not running a fever (she never took his temperature but he felt warm to touch). 3-31-11 2AM; the baby accompanied the family to the ER for another child''s scraped knee. They returned at 4AM, in which the mother reports she fed the baby 2 oz and did a diaper change. 10:40 AM the mother woke up and checked the baby, the baby was sleeping on his stomach. She reports that she does not believe in putting the baby on his back, because she thinks the baby will choke, she admits that she was trained by the provider, he should be on his back for sleeping. She then went out to the garage to have a cigarette. She returned at 10:50 am to get the baby up. The babies arm was flopped out and looked yellow, she checked the baby for breathing, and he was not breathing, then called 911. I gave the mother a copy of the child''s immunization record. Offered Healthy Start bereavement services, she declined, stating she has enough family support for that.


Changed on 5/14/2021

VAERS ID: 420337 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Florida
Vaccinated:2011-03-30
Onset:2011-03-31
Submitted:2011-04-05
Entered:2011-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B256CA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH254AA / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915192 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1074Z / 1 MO / PO

Administered by: Public      Purchased by: Public
Symptoms: Cold sweat, Death, Hypotonia, Respiratory arrest, Skin warm, Somnolence, Yellow skin, Hypophagia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-03-31
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: none
Current Illness: well baby
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: 4-1-2011 mother presents to clinic requesting child, immunization record. Mother reports that her baby died 3-31-2011 at approximately 10:50 am. She reports the following: On 3-30-11 at 12:30pm she brought patient to the CHD for a routine well baby visit and immunizations. The child was done with the visit and receiving his shots by about 1pm. The rest of the day the child was sleepy and ate about 2 oz of formula vs his normal 7 oz at a time. At 11:30 pm she performed his routine diaper change and feeding. At that time he was moist to touch, but not running a fever (she never took his temperature but he felt warm to touch). 3-31-11 2AM; the baby accompanied the family to the ER for another child''s scraped knee. They returned at 4AM, in which the mother reports she fed the baby 2 oz and did a diaper change. 10:40 AM the mother woke up and checked the baby, the baby was sleeping on his stomach. She reports that she does not believe in putting the baby on his back, because she thinks the baby will choke, she admits that she was trained by the provider, he should be on his back for sleeping. She then went out to the garage to have a cigarette. She returned at 10:50 am to get the baby up. The babies arm was flopped out and looked yellow, she checked the baby for breathing, and he was not breathing, then called 911. I gave the mother a copy of the child''s immunization record. Offered Healthy Start bereavement services, she declined, stating she has enough family support for that.

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=420337&WAYBACKHISTORY=ON


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166