Summary of Key Points of the HeadLice Clinical Report, Pediatrics (Official Journal of theAmerican Academy ofPediatrics)

Head lice infestation is associated with limited morbidity butcauses a high level of anxiety

There has been acall for greater physician involvement in the diagnosisand treatment of head lice.

ETIOLOGIC AGENT

The female lives up to 3 to 4 weeks and, once mature, can lay up to 10 eggs per day.

Note thatsome expertsrefer to “eggs” as containing the developing nymph and use “nits” to refer to emptyegg casings; others use the term “nits” to refer to both eggs and the empty casings.

Itching maynot developfor 4 to 6 weeks, because it takes that amount of time for sensitivity to result. If not treated, this cyclemay repeat itself approximatelyevery3 weeks.

EPIDEMIOLOGY

Head lice infestation is not significantly influenced by hair length or by frequent brushing orshampooing.

Infested individualsrarely havemore than adozen live lice.

TRANSMISSION

Lice cannothop or fly; they crawl.

Transmission in most cases occurs by direct contact with thehead of an infested individual. Indirectspread throughcontact withpersonal belongings ofan infested individual (combs, brushes, hats) ismuch less likely but may occur rarely. Lice found on combs are likely to be injured or dead.

In 1 study, examinationof carpets on 118 classroom floors found no licedespitemore than 14,000 live lice found on the heads of 466 children usingthese classrooms. In a second study, live lice were found on only 4% of pillowcases used by infested volunteers.Thus, the major focus ofcontrol activitiesshould be to reduce the number of lice on the head and to lessen therisks of head‐to‐head contact.

DIAGNOSIS

Diagnosis ofinfestationby using a lousecomb is quicker andmore efficient

Tiny eggs may beeasier to spot, especially at thenape of theneck or behind theears, within 1 cmof the scalp.

It's important not to confuseeggs or nits with dandruff, haircasts, or dirt.

Nits are more difficult toremove, because they are firmly attachedto thehair shafteggs found morethan 1 cm from the scalp are unlikely to be viable.

PREVENTION

It is probably impossible to prevent all head lice infestations.

Youngchildren come into head‐to‐head contactwith each other frequently.

It is prudentfor childrento be taught not to share personal itemssuch ascombs, brushes, and hats. However, no oneshould refuse towear protectiveheadgear because of fear of head lice.

In environmentswhere children are together, adultsshould be aware of the signsand symptomsof headlice infestation, and infestedchildrenshould be treated promptlyto minimize spread to others.

TREATMENT

Never initiate treatment unlessthere is a clear diagnosisof head lice.

Ideal treatment for licewould be completelysafe, free of harmful chemicals, readily available without a prescription, easy to use, and inexpensive.

The pediatrician (or someone in the community,such as theschool nurse) should be skilled in the identification of an active infestation with headlice to avoid treating patientsunnecessarilyor falsely identifying “resistance” in the community to a certain product.

Manual Removal

Nit removalcan bedifficult and tedious.

Studies havesuggestedthat lice removed by combing andbrushingaredamagedand rarely survive.

Shampoo hair twice perweek for 2 weeks and to vigorously comb out wet hair each time. The wet hair seems to slowdown the lice.

ENVIRONMENTAL INTERVENTIONS

If a person isidentifiedwith head lice, all householdmembers should be checked for head lice, and thosewith live lice or nits within 1 cm of thescalp should be treated.

Fomite transmission is less likely than transmission by head‐to‐head contact; however, it is prudent to clean hair care itemsand bedding used by theindividual with infestation.

Headlice can transfer topillowcases at night, but the incidence is low (4%).

CONTROL MEASURES IN SCHOOLS Screening

Screening for nits alone is not an accurate way ofpredicting whichchildren are or will become infested, and screening for live lice hasnot beenproven to have a significant effect on theincidence of head lice in a school community over time

Such screening has notbeenshownto be cost‐effective

Head lice infestations have beenshown to have low contagion in classrooms.

Often schoolchildrenare inappropriatelydiagnosed and treated.

Routine classroomor school‐widescreeningshould bediscouraged.

It may beuseful to provide information periodically about thediagnosis, treatment, and preventionof headliceto the families of allchildren.

Education of parentsin diagnosingand managing headlice may be helpful.

Parents should beencouragedto check their children’s heads for lice regularly and if the child is symptomatic. School screeningsdo not take the place of thesemore careful parental checks.

It may be helpful for theschool nurse or other trainedpersonto check astudent’shead if he or she is demonstrating symptoms.

Managementon the DayofDiagnosis

Confidentiality must bemaintained.

Prompt, proper treatment of thiscondition is in the best interest of the child and hisor herclassmates.

It may beprudent to check other children who were most likely to have haddirect head‐to‐headcontactwith the infested child.

In an elementary school, one waytodeal with the problem is to notify the parents or guardians ofchildren inan infested child’sclassroom, encouraging all children to be checkedat homeand treated, if appropriate, before returning to school the next day.

Alert parents only if a high percentage ofchildren in a classroom are infested.

“Alert letters” cause unnecessarypublic alarm and reinforce the notion that a headlice infestation indicates a failureon theschool’s part rather than a community problem

Designguidelines that bestmeet the needs of their studentpopulation, understanding that although a headlice infestationmay not pose a public health risk, it maycreatea public relations dilemma for a school.

Criteria for Return to School

Most researchersagreethat no‐nit policiesshould be abandoned; theAmerican Academy of Pediatrics and theNationalAssociationofSchoolNursesdiscourage no‐nit policies.

Nit removalmay beconsidered for the followingreasons: nit removal can decrease diagnostic confusion; nit removal can decrease the possibility ofunnecessaryre‐ treatment;and someexperts recommend removal of nits within 1 cm of the scalp to decrease thesmall riskof self‐reinfestation.

Perform a valuable service by rechecking achild’s headif requested to do so bya parent.

Offer extrahelp to families of children whoarerepeatedlyorchronically infested.

Reassurance of Parents, Teachers, and Classmates

Theschool can be mosthelpful by making available accurateinformationabout the diagnosis, treatment, and prevention of head lice in an understandable form to the entire school community: information sheets.

Child Care and “Sleepover” Camps

Child care centersandcamps wherechildrenshare sleepingquartersmay allow for easier spread.

Reminding parents of the importance of carefully checking a child’shead before and after a sleepover experience may be helpful.

Thecomplete reportmay be found at

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