HEAD LICE(PEDICULOSIS)

PROTOCOL

General Information

Head lice, also known as Pediculus humanus capitis, are tiny insects that live on the human scalp; they feed on human blood to survive; therefore, they are not found on, nor can be transmitted from, wild or domestic animals. In the United States, head lice infestation is seen more commonly amongpreschool and elementary school-aged children. Head lice are not a health hazard or a sign of poor hygiene; they are not responsible for the spreadof any disease.Historically, diagnosis of head lice infestations and the easy availability ofover-the-counter (OTC) pediculicides fortreatment essentially removed the physician from the treatmentprocess. However, the potential for misdiagnosis coupled with the improper use of pediculicides has raised concerns about unsafe useof these products, specifically when no lice are present orwhen these OTC products are used excessively. Because lice infestationis so benign, treatments must be safe so that theadverse effects of the treatment are not worse than the infestation (American Academy of Pediatrics (AAP), 2010).

Adult head lice are about the size of a sesameseed and can adapt to match the color of the hair.The female lives up to 3 to 4 weeks and can layup to 10 eggs per day. These tiny eggs are firmly attached tothe base of the hair shaft approximately 4 mm from thescalp with a glue-like substance produced by the louse. Empty egg casings (nits) are easier to see;they appear white against darker hair. The eggs (viable nits) typically hatch in 8 to 9 days (even up to 14 days depending on the climate temperature). Once hatched, a nymph leaves theshell casing and passes through a total of 3 nymph stages (instars)during the next 9 to 12 days and then reaches the adult stage (AAP, 2010).

There is no evidence that a no-nit policy prevents or shortens lengths of outbreaks (Pollack et al., 2000, Williams et al., 2001). The American Academy of Pediatrics (AAP), the National Association of School Nurses (NASN), and the Centers for Disease and Prevention are all opponents of no-nit policies (AAP, 2010; Schoessler, 2004).

Signs/Symptoms

Head lice do not transmit any disease agent.When infestations are symptomatic, itching of the scalp and back of the neck is the primary symptom caused by an allergic reaction to the louse saliva. Rarely,scratching may cause skin infection, and may need to see a provider.

Transmission

Lice cannot hop or fly; they crawl. Lice are generally transferred from one individual to another through direct head-to-head contact. While indirect spread throughcontact with personal belongings of an infested individual (combs,brushes, hats) is much less likely, it may occur. Licefound on combs are likely to be injured or dead; a healthylouse is not likely to leave a healthy head unless there isa heavy infestation.

Diagnosis

The gold standard for diagnosing head lice is finding a livelouse on the head; this can be difficult because lice avoidlight and can crawl quickly. Studies suggest that diagnosisof infestation by using a louse comb is quicker and more efficient. The tiny eggs may beeasier to spot; they are often found behind the ears and/or at the nape of the neck. They adhere to the hair shaft within approximately 1 cm from the scalp. It is important not to confuseeggs or nits with dandruff or other hair debris. Nits are more difficultto remove because they are firmly attached to the hair shaft. In general, eggsfound more than 1 cm from the scalp are unlikely to be viable,although some researchers in warmer climates have found viableeggs farther from the scalp.

Treatment

Parents should understand that the most important components of head lice control are a single treatment of an over-the-counter (OTC)permethrin (pediculicide), then reapplication if live lice are found seven to ten days later. Because none ofthe pediculicides are 100% ovicidal, manual removal of nits(especially the ones within 1 cm of the scalp) after treatmentis necessary to assure all viable nits are removed. Nit combing should also be performed. Nit removal can bedifficult and tedious. Fine-toothed "nit combs" make the process easier.Just washing the hair will not remove nits. If live lice are found 8 – 10 days after the second treatment, it is important that the parents contact their healthcare provider to verify treatment failure and initiate second-line therapy. Parent/guardian MUST bring a note from the doctor stating they have consulted with the doctor.

All household membersshould be checked for head lice: those with live lice ornits within 1 cm of the scalp should be treated. In addition,the AAP (2010) recommends treatment of family members who share a bed with theperson with infestation, even if no live lice are found.

Lice can become a costly and time-consuming problem. The BEST use of time is in removing the nits (lice eggs) from the hair. Research shows that approximately 30% of nits are still alive after lice treatment because no product is 100% effective against lice.

School/Nurse Responsibility

Screening for nits alone is not an accurate way of predicting which children will become infested, and screening for live lice has not been proven to have a significant effect on the incidence of head lice in school over time. Because of the lack of efficacy, classroom or school-wide screening should be strongly discouraged (AAP, 2010). Doing a classroom screening gives a false sense of security that those students do not have head lice. In actuality, either they haven’t hatched and one was present or the students get a louse another way but because he/she was checked we assume there isn’t a head lice issue. Because of that we may not check until further symptoms are evident.

Parents should be encouraged to check their children’s heads for lice if the child has symptoms (school screenings do not take the place of these parental screenings); therefore it is important to provide information to families of students who have been found to have active head lice on the diagnosis, treatment and prevention of head lice (AAP, 2010). (See Attachment A, Head Lice: Information for Parents/Guardians.)

School nurses should check a student’s head if he/she is demonstrating symptoms such as frequent scratching of head.It may be prudent to assess other children within the classroom who most likely were to have direct head-to-head contact with the child diagnosed with head lice. The school nurse should ascertain from the parent and/or child with active head lice if there are siblings of the child in other Hampton City Schools. If there are siblings, the school nurse should contact the school nurse(s) at the other school(s) to let them know your student has been found to have head lice/nits close to scalp and their sibling(s) should be checked as well.

Management on the Day of Diagnosis

If a child is assessed as having head lice, it is essential that confidentiality be maintained. Children found with live head lice should be referred to parents/guardians for treatment (NASN Position Statement). The AAP (2010) suggests that (within reason and using proper judgment)because a child with an active head lice infestation likelyhas had the infestation for 1 month or more by the time it isdiscovered and poses little risk to others from the infestation,he or she may remain in class but be discouraged from closedirect head contact with others,if feasible. The child's parentor guardian should be notified that day by telephone stating that prompt, proper treatment of this condition is inthe best interest of the child and his or her classmates. Common sense and good nursing judgment must be used in these cases when deciding how “contagious” the student may be (a student with hundreds versus a student with 2 live lice for example) when making the decision for the student to remain in class; remembering this student has had it at minimum a few days to up to a month already by the time of the exam. The parent/guardian of the student with head lice will receive SBO 400, Parent/Guardian Letter for Student with Head Lice (See Appendix B) and Head Lice: Information for Parent/Guardian (See Appendix A). The parent/guardian will need to pick up their child during the school day and may not ride home on the bus.

The nurse may determine the necessity to assess other children who most likely were to have direct head-to-head contact with the child diagnosed with head lice. The AAP (2010) suggests that, in an elementary school, it may be wise to notify the parents or guardians of all children in the child’s classroom, encouraging that all children be checked at home and treated if appropriate before returning to school the next day. Given the AAP recommendation, Hampton City Schools will do the following: Once a student in an elementary classroom has been found with live lice, it is recommended all students in that classroom receive a letter SBO 401, Parent Letter for Classroom Notification (See Appendix C). Again, nursing judgment must prevail.

Procedure for Checking a Student for Head Lice Infestation

  1. A brief explanation by the school nurse will be given related to what will be done.
  2. The examination will take place in the clinic, not in the classroom.
  3. When possible, direct sunlight or a high intensity lamp is advised when observing the scalp and hair for lice.
  4. Maintain privacy as best as possible when checking a student’s head for lice in the clinic.
  5. Pay particular attention when examining above and behind the ears and at the back of the head near the nape of the neck (the most common areas that nits are found).
  6. The hair should be separated using craft sticks so that the scalp and base of hair shaft is visible. A RobiComb® should only be used in the clinic with parental consent.
  7. Any lice found should be brushed into a Ziploc bag, which can be shown to the parent when they pick the student up.
  8. If the student, who has been identified as having lice, has a sibling(s) in the same school, the nurse should also examine the sibling(s). If any sibling is found to have lice, the nurse will make a determination whether further examination of students in the class needs to be made or only sending home the letter to all their classmates about lice being found in the class is appropriate. If sibling(s) attend another school, the nurse should contact the nurse at that school to inform of her student’s live lice diagnosis. That nurse should follow above procedures.
  9. Once lice have been confirmed, the nurse or designee will contact the student’s parent/guardian by phone and the parent/guardian will be informed the student needs to be picked up and may not ride home on the bus. Immediate removal of a student from the classroom is not necessary. A letter will be given to the parent/guardian regarding protocol, treatment, and follow-up procedures, and prevention. (See Appendix A and B)
  10. If the nurse determines it is prudent to check all students’ in the class Appendix C, Parent/Guardian Letter for Classroom Screening Notification will be sent home with every student that was screened.
  11. If this is an elementary school, you should consider sending a letter home notifying classmates’ parents that a case of head lice is suspected and asking parents to check their child for head lice. (See Appendix E, Parent/Guardian Letter: A Classmate Has Head Lice for letter).
  12. It is important to maintain confidentiality of any student(s) identified with head lice.

See Appendix D - Hampton City Schools Head Lice Flowsheet for nursing evaluation and follow-up care.

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Procedure for Follow-up Post Treatment

  1. A parent/guardian must bring the student to school post treatment, once it is determined by the parent/guardian there are no live lice found on student’s head.
  2. A student must be seen by the school nurse upon return to school post treatment.
  3. If any live lice are noted the student’s parent/guardian will be expected to take student home and seek medical guidance on further treatment, before returning to school.
  4. If the student does not have any live lice, the student will be checked at the seven (7) day point post treatment and the 14-day post treatment. At any point the student complains of itching he/she is to be instructed to return to clinic for check by the school nurse.
  5. Chronic/Frequent Recurrence Procedure: If a student has had three or more occurrences of head lice or has missed more than three (3) consecutive days or a total of five (5) days due to head lice the school nurse shall initiate a referral to the school social worker. The school nurse will also ensure the Principal has been kept abreast of the issue.

School Attendance Guidelines

  1. Students with definitive live lice may be sent home during the school day for appropriate treatment, depending on the school nurse’s assessment and findings. If the nurse, after contacting the parent/guardian and assessing the student, determines it is reasonable for the student to remain in school, the parent must pick the student up at the end of the school day. Students with live lice may not ride the bus home.
  2. If the parent/guardian discovers his/herchild has live lice, the child may not return to school until appropriately treated by the parent/guardian with no live lice evident and examined by the school nurse. The parent should contact the school, notifying attendance office and the school nurse that the student is home for treatment of head lice. The absence will be excused.
  3. Remember, the student may not return to school until appropriately treated. Treatment should occur the day the student has a confirmed case of live lice to minimize absences from school.Studentis tobe brought to school by the parent/guardian, once no live lice are present, the day after appropriate treatment. Parent/guardian and the student are to go to the clinic and the school nurse will check for live lice. The student must be cleared by the school nurse before going to class. Clearance will be given so long as there are no live lice.
  4. The student will be checked for viable nits every week for up to three weeks after initial treatment.
  5. The majority (but not all) of the nits will be killed by the appropriate treatment. Removal requires fine tooth combing using special metal combs, or mechanical removal using fingernails in order to prevent the possibility of re-infestation.

Guidelines for the Control orSpread of Lice for Classroom and Parents/Guardians

  1. A definitive diagnosis will help eliminate the unnecessary use of and potential resistance to pediculicides, so when there is doubt have a medical provider confirm before treatment.
  2. If a case is identified, follow recommended treatment procedures closely. Parents should report confirmed infestations of lice/nits to the school nurse so that close contacts can be screened.
  3. It is important to educate teachers, parents/guardians, and students about “head-to-head” contact, and stress not to share hats, hairbands, combs and/or brushes.
  4. Prevention steps can be implemented to decrease head lice transmission in the classroom (these are just a few suggestions):

Hang coats and book bags separately and spaced so they do not touch.

Have students put hats, gloves, and scarves inside coat pocket or book bag.

Educate students on ways to prevent the spread of lice. They should know the importance of not sharing hair care items and not sharing other student’s hats, scarves, clothes, etc.

Keep carpeted floors and upholstered chairs vacuumed.

Discourage stuffed animals in classrooms with young students since they often like to share toys.

Limit “dress-up corners” with shared smocks, hats, etc. because they can facilitate the spread of lice, especially during periods when there are known cases of lice infestations in the class.

5.School nurses need to teach parents/guardians that daily inspection, removal of any live lice and nits and treatment of the environment are crucial to preventing re-infestation. Additional information will be posted on the school division web site.

References

American Academy of Pediatrics (AAP), (2010). Clinical Report: Guidance for the Clinician Rendering Pediatric Care, Head Lice. Pediatrics, 110(3) September 2002, 638-643. Retrieved January 5, 2011, from

Center for Disease Control and Prevention (CDC), (2010). Parasites: Lice: Head lice. September 24, 2013, from

National Association of School Nurses (NASN), (2004). Position statement: Pediculosis in the school community. Retrieved on January 7, 2011, from