• Lice do not hop or fly. They are spread by direct head to head contact. Lice is rarely spread through accessories, such as hats and scarves. 
• Lice are most commonly found behind the ears and at the nape of the neck. 
• Head lice are most active in the dark and cause the most itchiness at night. 
• Lice are not indicative of a dirty house or child. Personal hygiene has nothing to do with getting head lice. 
• Lice eggs are small, grey-white and oval shaped and are commonly called "nits". Removal of nits require a fine comb and patience. We ask that you please do the following to help control the problem: 
• Encourage your child to wear hair pulled back, in a ponytail or braid. 
• Check your child's head daily.
  
  

The school nurse, as a student advocate and nursing expert, should be included in school district-community planning. Implementation, and evaluation of vector control programs for the school setting.

School nurses  are also in a pivotal position to dispel myths and stigmas regarding pediculosis by providing education. On the life cycle of the louse, methods of transmission, treatment options and care of the environment of the student's family, school and community at large.  

Additonal information can be found at: http://www.cdc.gov/parasites/lice/head/parents.html

Head lice (pediculosis capitus) are small parasitic insects that live on the scalp and neck hairs of their human hosts. The presence of lice is most often detected through the presence of adult lice or nits (eggs) attached to the hair shaft of the host, most often at the nape of the neck and behind the ears. Complications of infestations are rare and involve secondary bacterial skin infection (Lebwohl, Clark & Levitt, 2007). Pruritis (itching) is the most common symptom of a lice infestation, along with the following additional symptoms:

• a tickling feeling or a sensation of something moving in the hair;
• irritability and sleeplessness; and
• sores on the head caused by scratching. Sores caused by scratching can sometimes become infected with bacteria normally found on a person’s skin (CDC, 2010).

DESCRIPTION OF ISSUE

Some people consider pediculosis to be a public health issue that is brought into the school setting. Families and school staff expend innumerable hours and resources attempting to eradicate lice infestations, both live lice and their nits. The Centers for Disease Control and Prevention (CDC) (2010) reports an estimated 6 million to 12 million infestations (some experts believe that the true prevalence is considerably lower) (Pollack, 2010) occur each year in the United States among children 3 to 11 years of age. It is thought that head lice infestations are often misdiagnosed when medical and lay individuals identify the presence of lice based on the presence of eggs (Pollack, Kiszewski & Spielman, 2000). In addition, millions of dollars are spent annually on pediculicides, lice combs, physician visits, and parental time away from work. In an effort to find an easy, effective, and safe treatment, a variety of alternative therapies (e.g., occlusive agents such as oil-based and grease-based products, electric combs, herbal shampoos and enzyme solutions,) have been attempted by parents. There is little scientific evidence regarding the effectiveness of these alternative treatments, and all have an associated cost (Frankowski & Bocchini, 2010). Treatment recommendations for pediculosis should be based on evidence based literature from public health, medical and nursing content experts rather than anecdotal reports or commercial advertisements.

Parents, school staff, and the community often become unduly anxious when a case of head lice occurs within a classroom, and this anxiety is multiplied if more than one case is identified. A negative social stigma frequently accompanies the identification of pediculosis as well as the frustration involved with the cost, time and effort needed for treatment and environmental control (Gordon, 2007). It is important, as a part of a comprehensive educational program, that the school nurse emphasizes that head lice are not associated with poor hygiene (Lebwohl, Clark & Levitt, 2007).

In 2007, international guidelines established for effective control of head lice infestations reinforced that policies that required a student to be free of nits to attend school, known as “no nit” policies, were based on misinformation rather than objective science and were therefore unjust and should be discontinued (Mumcuoglu et. al., 2007). The CDC (2010) cites the following reasons to discontinue “no nit” policies in school:

• Many nits are more than ¼ inch from the scalp. Such nits are usually not viable and unlikely to hatch to become crawling lice, or may in fact be empty shells, also known as casings.
• Nits are cemented to hair shafts and unlikely to be transferred successfully to other people.
• The burden of unnecessary absenteeism to the students, families and communities far outweighs the risks associated with head lice.
• Misdiagnosis of nits is very common during nit checks conducted by nonmedical personnel.

RATIONALE

The school nurse is the key health professional to provide education and anticipatory guidance to the school community regarding best practice guidance in the management of pediculosis. The school nurse’s goals are to facilitate an accurate assessment of the problem, contain infestation, provide appropriate health information for treatment and prevention, prevent overexposure to potentially hazardous chemicals, and minimize school absence.

There is discussion in the scientific community on the best way to control head lice infestation in school children. No pediculicide is 100% ovicidal, and resistance has been reported with lindane, pyrethrins, and permethrin (Frankowski & Bocchini, 2010). New categories of pediculicides have recently been developed, including benzyl alcohol (CDC, 2010).

Head lice screening programs have not had a significant effect on the incidence of head lice in the school setting over time and have not proven to be cost effective (Frankowski & Bocchini, 2010). Research data does not support immediate exclusion upon the identification of the presence of live lice or nits as an effective means of controlling pediculosis transmission. By the time a child with an active head lice infestation has been identified, he or she may have had the infestation for one month or more and, therefore, poses little additional risk of transmission to others (Frankowski & Boochini, 2010). The school nurse is in a position to take the lead in eliminating school exclusion policies and, instead, incorporate evidence-based practices that reduce the stigma associated with head lice, and work to increase classroom time with an emphasis on keeping students in school (Gordon, 2007).

REFERENCES/RESOURCES
American School Health Association (2005). School policies in the management of pediculosis. Retrieved from
http://www.ashaweb.org/files/public/Resolutions/Pediculosis.pdf

Andresen, K., & McCarthy, A.M. (2009). A policy change strategy for head lice management. The Journal of School Nursing. 25 (6) 407-416. doi:10.1177/1059840509347316. 

Centers for Disease Control and Prevention (2010). Head lice information for schools. Retrieved from http://www.cdc.gov/parasites/lice/head/index.html

Frankowski, B.L,, & Bocchini, J.A.. (2010). Clinical Report-Head Lice. Pediatrics. 126(2) 392-403. Retrieved from http://pediatrics.aappublications.org/cgi/content/abstract/126/2/392

doi:10.1542/peds.2010-1308

Gordon, S. (2007). Shared Vulnerability: A theory of caring for children with persistent head lice. The Journal of
School Nursing. 23 (5) 283-292. doi: 10.1177/10598405070230050701

Lebwohl, M., Clark, L., & Levitt, J. (2007). Therapy for head lice based on life cycle, resistance, and safety considerations. Pediatrics 119 (5) 965-974. Doi: 10.1542/peds. 2006-3087

Mumcuoglu K.Y., Barker S.C., & Burgess I.F., et. al. (2007). International guidelines for effective control

of head louse infestations. Journal of Drugs in Dermatology. 6 (4) 409-414.

Pollock, R. J. (2010). How many people are infested with head lice? Retrieved from: https://identify.us.com/head-lice/head-lice-FAQS/how-many-people-infested.html 

Pollack R.J. , Kiszewski A.E., Spielman A., (2000). Overdiagnosis and consequent mismanagement of head louse infestations in North America. Pediatric Infectious Disease Journal. 2000 (8):689-93.

Acknowledgement of Authors:
Deborah Pontius, MSN, RN, NCSN
Carmen Teskey, BSN, MA, RN

Adopted: November 1999
Revised: July 2004, January 2011