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From the 12/31/2007 release of VAERS data (an older release, current is 2/18/2021):

This is VAERS ID 277567

Case Details

VAERS ID: 277567 (history)  
Form: Version .0  
Age: 0.6  
Sex: Male  
Location: North Carolina  
   Days after vaccination:18
Submitted: 2007-04-27
   Days after onset:12
Entered: 2007-04-30
   Days after submission:3
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: Unknown
Symptoms: Appendicectomy, Barium enema, Haematochezia, Intussusception, Surgery
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal haemorrhage (narrow), Ischaemic colitis (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: Unknown
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Information has been received from a registered nurse concerning a female who was vaccinated PO with a third dose of Rotateq. Subsequently, about a month after vaccination, the patient experienced intussusception. It was noted that the patient had surgery", but no additional information was available. There was no product quality complaint. Intussusception was considered to be immediately life-threatening and disabling and an other important medical event. Additional information has been requested.

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