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Assessing the evidence:

Treatents
for
!olic
"2
# The Breastfeeding $et%or&' (arch 2002
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Treatents for !olic
This paper considers the strength of evidence for di8erent treatents for colic' 3ut
frst it is %orth considering %hat is eant 3y colic4
9hat is the di8erence 3et%een crying and colic:
9hen colic is tal&ed a3out in 3a3ies it eans they are sho%ing a co3ination of
une+plaina3le irrita3ility' fussing and crying over a prolonged period often at the
sae tie each day' often in the evening' 3ut even this description is vague' if
failiar4 The 3a3y usually starts feeding then pulls o8 as if in pain' he ight dra%
his legs up as if in pain4 ;e can 3e soothed for a %hile if carried' or roc&ed 3ut if put
do%n the screaing starts again4 There is evidence of evening crying fro as far
3ac& as ancient <gyptian ties4 Translation of <gyptian hieroglyphics a3out faily
life records 3a3ies crying fro dus& until dead of night4i
The internationally used defnition of infantile colic is generally considered to 3e the
9essel ii defnition' %hich %as frst pu3lished in 1/044This allo%s 3oth the
syptos' fre=uency and duration of colic to 3e included4 >t is soeties %ritten as
9essel6s rule of threes' and is defned as:
?une+plained paro+ysal 3outs of fussing and crying that lasted @5 hours a day' for
@5 days a %ee&' for @5 %ee&s of duration4A
!olic is not uncoon' and the search for e8ective treatents has led to 5
di8erent systeatic revie%s %ithin the last 2 years: Bucasseniii' Carrisoniv' 9ade
and Dilgourv4 The incidence is said variously to a8ect 01/E FBucassenG' 16126E
FCarrisonG' 545117E F9ade and DilgourG of infants during the frst onths of life' this
variation depending on the ethods and defnition used4 *ne study suggested that
all 3a3ies no atter ho% they %ere fed %ere as li&ely to 3ecoe colic&y FBucassenG'
though the Stahl3ergvi study F686G sho%ed ore colic in 3a3ies Falready trou3led
%ith colicG %hen they %ere 3ottle1fed infant forula than pooled 3reast il& F8/E v
71EG4 Ba%rence states that colic&y 3reastfed infants %ho s%itch to forula usually
3ecoe uch %orse' though no reference is given4 Bucasvii found 3a3ies fed infant
forula cried ore at %ee& 2 than 3reastfed 3a3ies F45Ev16EG though 3y %ee&
6 the 3reastfed 3a3ies had overta&en the forula fed 3a3ies in tie spent crying
and 3eing a%a&e Fcrying @5hrs 51Ev12EG4 These results cae fro diaries
&ept 3y parents so %ithout an independent o3server the results are open to any
factors a8ecting relia3ility4 9e also don6t &no% if the 3reastfed 3a3ies %ere
e+clusively 3reastfed' or if 3reastfeeding %as 3a3y led4
9hat causes it:
is descri3ed as Hspasodic contraction of sooth uscle causing pain and
discofort6viiiFBa%rence p 286G4 Though Barri+ has an alternative theory' ta&ing the
focus a%ay fro %ithin the gastrointestinal tract' suggesting that for soe infants
the origin ay lie in the central nervous syste relating to the responsivity'
reactivity and regulation of the infant to his environent FBarr p61G4 All agree it is
li&ely to have a variety of causes' 3ut is still poorly understood4 !rying levels are
said to pea& at around 618 %ee&s' and have su3sided 3y 5 onths4
Treatents
A =uic& loo& in any parenting agaIine %ill sho% a nu3er of suggested treatents
for colic4 ;o%ever %e need inforation on the strength of the evidence for
these treatents4 *f the three systeatic revie%s availa3le > have ta&en ost
of the inforation fro the Carrison paper' %ith soe additional detail fro 9ade
and Dilgour4 The other revie% 3y Bucassen has 3een criticised 3y Carrison for its
design' for not including all possi3le colic treatents' and for including trials that
failed to eet Carrison6s inclusion criteria4 > too consider the Bucassen paper to
have ethodological pro3les that a8ect its relia3ility 1 several letters+ %ere
pu3lished in response criticising the article4 ;o%ever in a letter to )ediatrics'
Bucassen+i defends his paper and criticises Carrison in return' %hich Carrison
refutes4
Carrison6s systeatic revie% descri3es the search strategy and the standard
data3ases used4 Dno%n authors %ere contacted for additional inforation
including unpu3lished trials %hich in this conte+t is especially iportant as
studies sho%ing no e8ect are harder to pu3lish' this can lead to the true e8ect of an
intervention 3eing overestiated+ii4 <ach trial %as assessed for =uality' ho% the
groups %ere divided and %hether the parents or researchers &ne% %hether the
3a3y %as having the treatent or acting as the control4 They e+plain ho% this
dou3le 3linding %as crucial as colic has such a high place3o response rate %here
any
# ) Buchanan and the Breastfeeding $et%or&
(arch 2002
1
iproveent in crying is often an ipression rather than a defnite easure4 They
agree %ith others in this feld that the ideal defnition of colic is the 9essel
defnition' and this is used throughout4
Their search revealed a total of 05 articles' only 22 randoised controlled trials et
their criteria' of these / defned colic ade=uately and 12 had parents and health
%or&ers una%are of %hich treatent they %ere ta&ing4 *nly 0 trials %ere
considered ade=uate in all these areas to eet the 3asic screening test4
The ost coonly used colic treatent o8ered to parents contains siethicone
FinfacolG and this %as sho%n to have no e8ect on reducing syptos of colic4 The
other %idely advertised treatent using lactase enIyes for suggested lactose
intolerance Feg !oliefG also sho%ed no e8ect4 The only drug treatent that sho%ed
any e8ect' Jicycloine Fer3entylG is no% considered unsafe for 3a3ies under the
age of 6 onths and therefore is not availa3le for 3a3ies %ith infantile colic4 The
trial testing a hypoallergenic diet is 3est seen as t%o separate trials4 The
3reastfeeding others %ere all given a diet free of food dyes' additives and
preservatives and %ere also randoised to an active diet that %as also free fro
dairy' eggs' %heat and nut products or a control diet4 The 3a3ies 3eing artifcially
fed %ere randoised to receive hypoallergenic il& or a standard co%6s il& 3ased
forula4 Knfortunately the results fro 3oth these groups are co3ined and only
Lust reach signifcance4 !ates and Buchanan =uestioned this in response to the
Bucassen study and despite Carrison noting our concerns the results reain pooled4
Boo&ing at the ;ill+iii study in ore detail still doesn6t help4 There %as no signifcant
di8erence 3et%een the iproveents noted 3y the others of 3a3ies in the active
diet group copared to the control group4 >nterestingly the 3a3ies trying the
hypoallergenic il& instead of standard forula didn6t see to li&e the taste as
there %as a 47E drop1out rate in this section of the trial4
>ncreased carrying for at least 5 hours per day' %hether or not the 3a3y %as crying
%as not found to reduce syptos Fas descri3ed in 9ade and DilgourG 3ut no
record is given of the parents6 vie%s on %hether it helped the or their 3a3ies cope
%ith the colic' as Ba%rence says H$o type of crying should go untended in a young
infant4 ;olding and roc&ing do not spoil infants46Fp288G
The trial on her3al teas %as found to help reduce colic 3ut no ention is ade to
the potential har it ight have on the 3reastfeeding relationship4 >t could also
have eta3olic conse=uences' a8ect the infant6s gut and Carrison raises concerns
a3out potential nutritional e8ects of prolonged treatent leading to a decreased
inta&e of il&4 Bandolier6s vie% is stronger H(ay 3e slight e8ect in single study' 3ut
sensi3le parents unli&ely to try this in sall infants46
So despite all the availa3le research as Bandolier puts it Hthe siple fact is that
there is no evidence that any intervention is e8ective4 .or today6s us and dads
all %e can o8er is the &no%ledge that their screaing infant %ill gro% out of it46
Carrison recoends future studies to loo& at specifc groups of 3a3ies or %ith
suspected causes 3efore testing treatents4 Studies also need to 3e larger to have
any relia3ility4
Specifc Breastfeeding options
Although this revie% considers the evidence for various %ays of treating colic it
doesn6t ean that these are the only options4 The ain focus of these treatents
is on fnding soething that can 3e used for forula fed and 3reastfed 3a3ies ali&e4
,et there are %ays of anaging colic that apply specifcally to 3reastfed 3a3ies and
this is usually issing fro any revie% of treatents4 .or e+aple' there is soe
evidence that a&ing sure the 3a3y is %ell positioned ay lead to a reduction in
colic+iv4 The iportance of fnishing the frst side frst is also helpful in reducing
colic+v +vi4 So for 3reastfed 3a3ies' anaging colic ight start %ith %atching the
3a3y during a %hole 3reastfeeding episode loo&ing at positioning and
attachent until the feed is fnished4
(aternal diet
There ay 3e a faily history of allergies and an association %ith dairy products in
the other6s diet has 3een investigated' though as Carrison reports results are not
conclusive4 9ithin the ;ill study Fsee a3oveG those others on the hypoallergenic
diet noticed a greater iproveent in colic %ith 3a3ies younger than 6 %ee&s'
though nu3ers %ere too sall to 3e of signifcance4
According to Ba%rence Hacute 24 hr colic in a 3reastfed 3a3y ay result fro a
particular ite in the aternal diet4 !olic inducing foods are di8erent for di8erent
infants' the ost li&ely foods to cause colic are given as: cruciferous vegeta3le
Fsuch as cauliMo%erG' onions' co%6s il& and chocolate and less li&ely %ith
3eans' legues' spicy foods and ca8eine64 An association %ith diet drin&s have also
3een found+vii4
2 # ) Buchanan and the Breastfeeding $et%or&
(arch 2002
Although the evidence is liited a3out avoiding particular foods it is %orth noting
that soe' especially dairy products need to 3e e+cluded for a3out 2 %ee&s to see
an e8ect4 This eans reading the sall print on all food to loo& for traces of the
suspected food4 (il& can 3e included as an ingredient in the ost une+pected foods
including sausages and 3iscuits4
$e% research ho%ever suggests another echanis to e+plain the allergic
response in 3a3ies %hich ay 3e associated %ith soe causes of colic4 ;oppu+viii
suggests that the presence of dietary antigens in 3reastil& having 3een odifed
3y the other6s gut ay 3e ideal for the aturation of the 3a3y6s iune syste4
;e highlights the role of gro%th factor present in 3reastil& in stiulating intestinal
gro%th and developent' so interruption of e+clusive 3reastfeeding ay a8ect the
aturation of the infant6s gut4 So although his paper focuses on reducing allergies
the suggestions a3out altering diet ay 3e an idea %orth trying as a eans of
reducing colic4 This involves reducing the saturated fat content of the other6s diet
and increase the aount of fresh fruits and vegeta3les and fat fro vegeta3le
origin Fthough current concerns a3out peanut allergies ight a&e these %orth
avoidingG4
!olic and !hiropractic Treatent
There have 3een t%o randoised trials loo&ing at the e8ect of chiropractic
treatent on colic4 The frst a Janish study+i+' loo&ed at the e8ects of
chiropractic on colic&y 3a3ies4 Ba3ies Loined the study if the assessent 3y
health visitor nurses sho%ed they et the 9essel criteria for colic Fargua3ly
odifedG4 *ne group of 20 3a3ies received spinal anipulation for t%o %ee&s4
The other group of 20 %as treated %ith diethicone Falso &no%n as siethiconeG
for t%o %ee&s4 <8ect on crying easured 3y daily hours of crying in a colic diary4
.ro day 0 the anipulation group did signifcantly 3etter than the diethicone
group4 Fone hour reduction of crying %ith diethicone v 247 hours %ith
anipulationG4 This study %ould have 3een e+cluded 3y the Carrison revie% as
there is no control group4 Soe of the 3eneft is li&ely to 3e the place3o e8ect'
though it is argua3le that as diethicone has 3een sho%n to have no conclusive
3eneft' this could give a 3ase line for a place3o e8ect4 ;o%ever coupled %ith the
a3sence of dou3le 3linding Fthe others &ne% %hich treatent group their 3a3y
%as inG it could have a8ected the results and %ith a drop out of /-20 3a3ies in the
diethicone group including 0 %ithin the frst %ee& caution should 3e used %hen
loo&ing at this study4 The study did ensure the interpretation of the colic diaries %as
carried out 3y an o3server %ho %as una%are of the treatent group4 The
chiropractic intervention loo&s li&e it had a positive e8ect 3ut further studies
are needed4
The second study fro $or%ay++ is larger %ith 100 3a3ies %ith colic 3eing
recruited4 The selection criteria %as thorough 1 they et the 9essel6s defnition' the
others had tried a co%6s il& free diet for 4 days' or 3a3ies had hypoallergenic
forula if artifcially fed' they tested negatively for lactose intolerance and %ere
other%ise %ell4 ;o%ever despite the detail given in this study it fails to consider the
ipact of age variation across the t%o groups and there are soe signs that the
control group ay have 3een older' as they had a slightly longer duration of colic
N546 v 445 %ee&s' pO04062P4 !olic decreases %ith age so it is possi3le that the
control group %as resolving at a faster rate4 (ore 3a3ies %ere 3reastfed in the
treatent group 3ut again this did not reach signifcance N/540Ev80E' pO04075P4
This study %as dou3le 3linded' the nurse too& the 3a3y a%ay fro the other
3efore treatent so she didn6t &no% %hether the 3a3y had spinal anipulation or
not4 The results sho%ed an iproveent in 3oth groups' 6/4/E treatent v 60E in
the control group NpO04574P4 So in this study chiropractic treatent %as no ore
e8ective than the place3o in reducing colic' though as one revie%er F(idirs
a3stractG has pointed out e8ective spinal anipulation ay have 3een diQcult
%hen a 3a3y is reoved fro his other4
So&ing
>n a national saple of 5540 Jutch 3a3ies++i aged 116 onths the incidence of colic
%as dou3led if the 3a3y %as forula fed and the other so&ed' adLusted *R 1481
F1421 to 2472G4 The ris& of colic %as lo%ered if the other %ho so&ed also
3reastfed her 3a3y' partial 3reastfeeding *R 1418 F0460 to 2452G4 >t is suggested that
e+posure to the products of so&ing during pregnancy ay a8ect the infant in
soe %ay4
(anaging !olic
As& a Breastfeeding Supporter to %atch a %hole 3reastfeed' until the 3a3y
coes o8 the 3reast
even good positioning ight 3e ade 3etter4
>f there sees to 3e plenty of il& %ith 3oth 3reasts 3eing used at each feed
gradually changing over several days to using one 3reast per feed %ill help
decrease the volue of il&4 ?.inishing the frst 3reast frst'A anecdotally this can
3e e+tended for varying lengths of tie till an e8ect is found' for soe &eeping to
one side for an hour helps' for others 5 hours at a tie is needed++ii' longer ties
# ) Buchanan and the Breastfeeding $et%or&
(arch 2002
5
have 3een noted too4 This is thought to help 3y giving the 3a3y a lo%er1volue'
higher1fat feed4 Jiscuss this %ith a Registered Breastfeeding Supporter4
>f you feel il& is coing too fast so that the 3a3y coes o8 crying or pulling o8
the 3reast it
soeties helps to feed %ith the 3a3y sitting upright or the u lying on
her on her 3ac&' %ith the 3a3y on top of her 1 so the il& Hgoes uphill64
!onsider 3a3y led feeding v restricted feeds4 Soe parenting 3oo&s o8er
a rigid style of
3reastfeeding' resulting in feeds 3eing restricted 1 colic can 3e iproved 3y
feeding to the 3a3y6s needs4
>f none of the a3ove helps' you ay %ant to consider teporarily eliinating
certain foods %hich ay
3e lin&ed %ith colic fro your diet Fsee a3oveG to see %hether this a&es
any di8erence 1 particularly if you su8er fro astha or ecIea yourself4 As
already entioned' if using this ethod dairy products in particular ay need to 3e
e+cluded for a3out 2 %ee&s to see an e8ect4 Alternatively the diet suggested 3y
;oppu could 3e tried' increasing the aount of fruit and vegeta3les in the diet' and
reducing the aount of saturated fat and replacing this %ith fat fro vegeta3le
origin4
)hyll Buchanan' Bf$ Breastfeeding Supporter
%ith than&s to !arolanne Baont' Sane Britten' 9endy Sones and (agda
Sachs 4
.urther reading
Bestfeeding: Cetting 3reastfeeding right for you4 Renfre%' .isher and Ars4 2nd
edition !olic case study on p18411804 so&ing and colic is discussed on p/4
The Breastfeeding Ans%er Boo&4 BBB> Revised <d (ohr3acher $ and Stoc& S4 p5815/'
8/1/0 Breast is Best4 Stan%ay )TA4 5rd <d )an 3oo&s >SB$ 0550547050 p1/61202
The Kltiate Boo& of Breastfeeding Ans%ers4 $e%an S' )itan T4 >SB$
076102//6/ )ria )u3lishing !hapt / p17011//
The Breastfeeding Atlas4 1///' B 9ilson1!lay' D ;oover p57'58
Resources online fro the Australian 3reastfeeding association 1 Bactose
intolerance and the 3reastfed 3a3y4 Anderson S
%%%43reastfeeding4asn4au-3fnfo-lactose4htl
9hy is y 3a3y crying: %%%43reastfeeding4asn4au-3fnfo-%hycry4htl
4 # ) Buchanan and the Breastfeeding $et%or&
(arch 2002
!olic Treatents
>nterventions that sho%ed soe e8ect
*utcoe Resolution rate
>ntervention easured >nfants FE' noG !oent
place3o treated
Jicycloine <liination of 20E 65E RRO 040' /0E!>O
0428104884 pO U 4
01 n O 154
Fe4g4 er3entylG colic 4/ 4/ Adverse e8ects'
soe serious
reported in infants
and drug
contraindicated in
infants less than 6
onths
;ypo1allergenic Jaily 45E 61E RR O 1445V /0E!>
O 1400124064 pO 4
047 nO58
artifcially fed' nO
77 3reastfed
diet reduction of )oor study design
in the ;ill study
i+es results fro
3reastfeeding
others
coparing a diet
avoiding il&'
%heat' egg
syptos and nuts %ith
noral food and
3a3ies coparing
hypoallergenic
il&s %ith
standard forula4
(isleading study'
results
04 61 should have 3een
considered as t%o
di8erent trials
loo&ing separately
at 3reastfed and
artifcially fed
3a3ies4
Trial of
hypoallergenic
il& v standard
forula had a 47E
drop1out rate
Soy forula <liination of 0E 68E RR O 0455V/0E!>
O 40171 4604 p U 4
001 n O 108
colic *ne study sho%ed
iproveent'
%hile larger of the
t%o did not4 The
results of second
study are not
given in a useful
1/ 1/ %ay4 $either study
ade any attept
to disguise the soy
forula so it %ould
have 3een o3vious
%ho %as getting
the
ne% treatent4
(ay have an e8ect
on artifcially fed
3a3ies 3ut needs
further research 1
no discussion on
&no%n hars4
Jecreased >proveent 00E /5E RR O 1487V /0E !>
O 1404154544 p O
U 401 n O 42
stiulation o3served Ba3ies %ithout
colic ay have
3een included in
this trial4 Bi&ely to
sho% 3ias4
22 20
;er3al tea <liination of 26E 07E RR 0407V/0E !>
04571048/' p O U 4
01 n O 68
colic Said to have a
control group 3ut
3oth groups got
3ottles of tea' one
%ith her3s' the
other %ithout4 $o
discussion on
55 50 possi3le hars
this could cause 1
too uch Muid
replaces il& and
can have
eta3olic
conse=uences4
>nterventio
ns that
sho%ed no
e8ect
>ntervention $o of $o of !oent
trials infants
Siethicone 5 272 The largest and ost
relia3le of these trials
sho%ed no e8ect' even
for those 3a3ies
considered Hgassy6 3y
parents4 The other 2
had design
Ma%s' one sho%ed no
e8ect' the other an
e8ect on days 4174
<+isting data does not
sho% conclusive
3eneft of siethicone
as a treatent
Fe4g4 infacolG for infant colic4
>ncreased carrying 2 /4 $o e8ect on crying 3ut
no inforation a3out
the parent6s vie%s4
Sucrose 2 72 (inial e8ect Fless
than 5 inutesG
Bactase enIyes 1 20 Bottle fed only 1 3a3ies
given co%s il& soe
days and pooled 3reast
il& on other days 1 no
e8ect Fsee
coentaryG
Fe4g4 coliefG 1 24 Breastfed only 1 no
e8ect on sleeping'
crying or feeding4
.i3re enriched 1 04 $o e8ect on average
tie spent crying4
forula
(ethyl1 1 40 $ot e8ective or safe for
3a3ies
scopolaine
Feg hyoscineG
!ar ride siulator 1 52 $o e8ect on crying or
aternal an+iety
)arent training 1 14 Soe e8ect 3ut trial
sall and li&ely to sho%
3ias4
# ) Buchanan and the Breastfeeding $et%or&
(arch 2002
0
i
1 !o+ S4 Breastfeeding 11 > can do that4 1//7 ) 10
ii
9essel (A' !o33 S!' Sac&son <B' ;arris CS' Jet%iler A!4 H)aro+ysal fussing in
infancy' soeties called ?colic4A 6 F1/04G )ediatrics 1444211454
iii
Bucassen )BBS et al4 <8ectiveness of treatents for infantile colic: systeatic revie%4
Br (ed S 1//8V 516:1065106/
iv Carrison ( !hrista&is J4 A systeatic revie% of treatents for infantile colic4 )ediatrics
Wol4106 $o1 Suly 20004 p 1841/0
A3stracted as Treatents for infant colic' Bandolier Sep 2000V 7/14
http:--%%%4Lr24o+4ac4u&-3andolier-3and7/-37/144htl
v
9ade S' Dilgour T4 >nfantile colic4 B(S 2001V525:4571440
vi
Stahl3erg (R Savilahti <4 >nfantile colic and feeding4 Arch Jis !hild4 1/86V61:12521
1255 vii Bucas A' St Saes1Ro3erts >4 !rying' fussing and colic 3ehaviour in 3reast1 and 3ottle1
fed infants4 <arly huan Jevelopent 1//8V 05: p/11/
viii
Ba%rence RA' Ba%rence R(4 BreastfeedingV a guide for the edical profession4 0th
<dition4 (os3y >SB$: 0810126108
i+ Barr RC' ;op&ins B' Saes A4 Creen SA !rying as a Sign' a Sypto and a Signal4 (acDeith
)ressV >SB$: 18/8685212
+ Betters in response to <8ectiveness of treatents for infantile colic: !ates !4 Jietary
interventions in 3reast fed and 3ottle fed infants should not 3e pooled4 Buchanan )4 Trial of
hypoallergenic il& is not supported 3y strong enough evidence4 B(S 1//8V517:1401 plus
several ore letters %ith other coents4
+i
Bucassen )BBS' Assendelft 9SS4 >n reply Carrison ((' !hrista&is J4 Systeatic Revie%
of Treatents for >nfant !olic4 )ediatrics Wol 108 $o4' *ct 2001 p1047
+ii
The !ochrane Revie%ers6 ;and3oo& Clossary4 Wersion 44144 Kpdated (arch 2001
+iii
;ill J et al4 A lo% allergen diet is a signifcant intervention in infantile colic: Results of a
counity 3ased study4 S
Allergy and !lin >unol4 Jec 1//0V/6:88618/2
+iv
Righard B' Alade (4 Suc&ing Techni=ue and its e8ect on success of 3reastfeeding'
Birth 1/:4 Jec 1//2' p1801188 +v 9oolridge (' .isher !4 !olic' overfeeding' and syptos
of lactose ala3sorption in the 3reastfed 3a3y: a
possi3le artifact of feed anageent: Bancet 2' no48607 F1/88G: 5821584
+vi <vans D4 <8ect of the ethod of 3reastfeeding on 3reast engorgeent' astitis and
infantile colic4 Acta )aed 84: 84/
1 02' 1//0
+vii
)ersonal counication' Borna ;art%ell
+viii
;oppu K et al4 Breast il& 1 iunoodulatory signals against allergic diseases4
Allergy 2001: 06: Suppl4 67: p2526
+i+ 9i3erg S(' $ordsteen S' $ilsson $4 The short1ter e8ect of spinal anipulation in the
treatent of infantile colic: a randoiIed controlled clinical trial %ith a 3linded o3server4
Sournal of (anipulative and )hysiological Therapeutics' vol 22' no 8' *ct 1///' pp 01710224
Revie%ed in (idirs Jec 2000' Wol 10:4
!oent fro Wol&ening J in: S (anipulative )hysiol Ther4 2000 SunV25F0G:5604
++ *lafsdottir < et al4 Randoised controlled trial of infantile colic treated %ith chiropractic
spinal anipulation4 Archives of Jisease in !hildhood' Wol 84' no2' .e3 2001' p 1581141
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