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05:42 PM

New AAP head lice guidelines - a real head-scratcher

The Doc Smitty nit picks at AAP guidelines on lice

I’m not afraid to step into controversial pediatric topics. I’ve covered essential oils, HPV vaccination and many others.

But I was surprised when I stepped into another HUGE controversy on my Facebook page a while back while discussing head lice.

Wait? Head lice?

It shocked me because I can usually predict which topics will spark heated debates. Not this time.

The cause of concern were a group of guidelines in Pediatrics last week which covered the transmission, diagnosis and treatment strategies for head lice.

The guidelines mention a few general points about lice that are important:

1. Head lice, while they can be very frustrating and costly to treat, do not carry or spread disease.

2. Despite the stigma associated with them, they are not a sign of poor hygiene.

3. Most lice can be treated with over-the-counter remedies, but resistance does occur and there are stronger medications available by prescription.

The parts of the guidelines that caused the uproar are those that surround the management of children with lice at school. There are three main points:

1. Routine screening of children is not necessary.

2. Children should not be required to go home on the day lice are discovered.

3. Children should not be excluded from school based on nits alone.

Before you get too upset, there is some science behind the recommendations and it’s related to two factors: the ability to diagnose lice even if one looks carefully and the way that lice are spread from child to child. Here are some facts:

  • Lice are very common. Next to the common cold, it is the second most common “communicable disease” in elementary age kids. Many children who have lice will not have symptoms.
  • Contrary to what you might have heard or think, lice do not jump from head to head (they must crawl through direct contact). In fact, they are very unlikely to leave a head for another unless there is a high level of infestation. Lice do not commonly pass from person-to-person on inanimate objects. Most studies done on combs and other objects show that the lice can transfer but they are often found to be dead.
  • Nits can be present for months after treatment. Only somewhere between 10 and 30 percent of kids with nits will actually have a live infection in the future. Studies have shown that doctors, nurses, parents and teachers often confuse nits with active infection. Specimens sent that were thought to be lice were actually a piece of dirt, dandruff or other debris.
  • The stigma associated with head lice can be damaging. Frequent shampooing and brushing do not protect one from acquiring head lice. Parental response to a case of head lice in a particular child or in the child’s classroom can create significant, unnecessary anxiety.

So, now that we have the facts out there, let’s go back through the guidelines with an added dose of common sense.

Routine screening of children is not necessary. Because screening does not always identify infection and the discovery of nits does not always indicate risk for infection, screening the whole school randomly does not appear to be a valid strategy for control or prevention of lice. It is prudent to screen the household members of an infected child and to treat anyone who shares a bed with the child. I also think it would be appropriate to screen a classroom in an instance where more than one case has been discovered. There is no evidence to support this practice, but logic would say that the more cases that have been found in a class, the more likely other children are at risk. Screening is best done in the home by the parents (and studies show that training them how to look is helpful), but a school nurse can be a valuable resource when children are demonstrating symptoms and in cases of uncertain diagnosis.

Children should not be required to go home on the day lice are discovered. This is the one that got everyone mad at me last time. Let’s think through why the recommendation is there. Because most infections in children are without symptoms, it is likely that a child who is discovered to have lice has likely had that infection for days to weeks prior to discovery. The logic is that having them at school for another few hours, when they have already been in class several days is not likely to pose a large risk to other classmate.

Here are some (very reasonable) objections I heard:

1. I think as children get older, they can begin to understand that if lice are discovered they should practice caution and not approach, hug or otherwise have their heads near other children (#noselfies). In younger children and in children with developmental disability or cognitive delay, it may be prudent to go ahead and make a phone call to the parent to have the children picked up. They may not understand instructions to keep a safe distance from other kids. Infection in this population may lead to secondary complications of scratching like infections and bleeding.

2. "Parents should be given the option to start treatment right away." Yes! I believe that we should go ahead and call the parents right away and let them know that their child has lice. They can pick the child up and start treatment right away if they desire; but, in most cases, a parent should not be forced to come and pick up their child immediately. Even if they don’t pick up the child it might give them a chance to pick up some medication over their lunch break which could increase their odds of getting treatment that night.

3. "Children will not even be able to concentrate because their head itches so why keep them there?" Clearly, if the scratching is a disruption to the child or the classmates, it could be a reason to call the parent to ask them to pick up the child and start treatment. However, this is most often not the case. Many children will be asymptomatic even with significant infection.

Sending a child home immediately can send the wrong message to the rest of the class regarding the stigma of lice. “Get that child away because they are unclean.” There have been estimates that as many as 25 percent of kids will have lice in a given school year. There are probably other kids in the same class who also have lice.

Who might need to be sent home with lice?

1. Children with developmental or cognitive delays who do not understand keeping their distance and whose classmates are more likely to have secondary complications from scratching.

2. Children of parents who do not recognize the importance of treatment or who are not compliant with treating appropriately.

3. Children who have hundreds of live lice vs. those that require searching for 10 minutes to find two live lice.

Children should not be excluded from school based on nits alone. Most of the commenters actually agreed with this recommendation (although some did not). Nits are very common and are not necessarily indicative that active infection will begin. In addition, despite adequate treatment, nits can persist for months after good treatment. “No-nit” policies have more or less gone away from schools after the 2010 guidelines.

The new 2014 lice guidelines are based on the scientific evidence that is available regarding lice infection and treatment. There need to be more studies done on these issues but, I believe, with some subtle distinctions and common sense, they can be implemented across schools to keep as many kids present as possible while still protecting their classmates from infection.

Learn more about lice - the treatment, prevention and getting rid of them here.

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Comments 1 - 2 (2)
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Ashley Salyers
Thank you for this article! As a registered nurse who has spent the last 13 years as a school nurse, I appreciate your stance on this topic. I completely understand head lice is a nuisance, but it drives me insane to see it often referred to as a communicable disease in school health policy/procedure manuals. My goal as a school nurse is to keep kids in the classroom where instruction occurs. Every student excluded from school due to head lice is missing valuable instruction that often cannot be made up. My hope is that we can continue to educate parents, teachers and administrators on this topic in an effort to change school district policies. I also strongly believe education on head lice treatment for parents is crucial. There are too many myths regarding treatments, which in turn compounds the issue.
Betty Thompson
I have been a school nurse since 1991. So many emotions and reactions from staff, students and parents related to the anxiety of thinking a student has head lice is exhausting. Education on this topic is very much needed and appreciated. This article was easy to read and remember. Thank you for taking on this topic that most do not feel is important until they are faced with it.