From the 2/26/2021 release of VAERS data:

This is VAERS ID 294705

Case Details

VAERS ID:	294705 (history)
Form:	Version 1.0
Age:	0.18
Sex:	Male
Location:	California

Vaccinated:	2007-09-11
Onset:	2007-10-24
Days after vaccination:	43
Submitted:	2007-10-29
Days after onset:	5
Entered:	2007-10-29

Vaccination / Manufacturer	Lot / Dose	Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS	AC21B090AA / 1	UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC.	0079U / 1	UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH	B474420 / 1	UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	1167F / 1	MO / PO

Administered by: Other Purchased by: Public
Symptoms: Intussusception
SMQs:, Gastrointestinal obstruction (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Xray tests LABS: abdominal x-ray & US c/w ileocolic IS. Air reduction enema successfully reduced IS.
CDC Split Type:

Write-up: Hospitalized with intussusception on 10/24/07. 12/4/07 Reviewed vax record which confirms dose & lot numbers as reported. Records faxed to CDC. 12/7/07 Reviewed hospital medical records which reveal patient experienced vomiting & bloody stool. Had been seen at outlying ER & transferred to higher level of care. Admitted 10/24/2007 & d/c to home same day. FINAL DX: Intussusception, enema reduced. Records faxed to CDC.

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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=294705