1. Going to School on Head Lice
New Approaches to an Old Nemesis
Going to School on Head Lice: New Approaches to an Old Nemesis
Head lice infestations are a fact of life, as school nurses know all too well. They are often the first professionals to deal with the situation, a scenario in which myths and misinformation abound and emotions run high. The school nurse has a unique opportunity to shape the school’s, the family’s , and the community’s response to head lice infestations; to assist in the development of evidence-based approaches to these unwanted visitors; to educate parents, teachers, school officials, and community leaders; and to advise families to seek help from their health care provider when deciding among treatment options.
Professional organizations such as the American Academy of Pediatrics (AAP), National Association of School Nurses (NASN), and Centers for Disease Control and Prevention (CDC) are now urging clinicians to become more knowledgeable about head lice and more directly involved in its diagnosis and treatment. The goal is to provide clinical guidance to families who are coping with head lice and to ensure the appropriate use and prevent the misuse of head lice products.
This presentation outlines 3 pivotal roles for the school nurse in the management of head lice infestations—first responder, family and community educator, and advocate for evidence-based treatment and policies. All of these roles serve the greater goal of helping families more efficiently respond to and resolve the daunting challenges that head lice bring. To facilitate these roles, the presentation provides pertinent clinical details about head lice and their habits; describes a newly evolving approach to diagnosis and treatment that is designed to avoid the possible dangers of not following treatment instructions; and offers practical advice for handling outbreaks with a cool and level head.
Getty Images/Digital Vision.
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2. Key Points to Cover Today!
Head Lice: Getting to Know You
The Key Role of the Clinician in Head Lice Diagnosis and Treatment
The School Nurse’s Pivotal Roles in Head Lice Management
Strategies for School Nurses: When Lice Go to the Head of the Class
Background Information on Approved Head Lice Products
Key Points to Cover Today! 2

3. Head Lice: Getting to Know You

4. Head Lice Infestation: A Common Pediatric Condition
Pediculosis is the most prevalent parasitic infestation among humans1
Head lice infestations are pervasive among school-age children in the United States2,3
~6-12 million infestations occur each year in children 3-11 years of age3
More common in females4
All socioeconomic groups are affected2,4,5
Contrary to myth, “head lice prefer clean, healthy hosts”4
Getty Images/Peter Dazeley.
Head Lice Infestation: A Common Pediatric Condition
Head lice is the most prevalent parasitic infestation among humans.1 Young children of preschool and elementary school age are the usual targets of this common infestation, most likely the result of head-to-head contact when they are at play.2-4 Less often, transmission may occur as a result of sharing inanimate objects—for example, clothing, hair combs, and brushes—especially in warmer climates in the summer.4 An estimated 6-12 million infestations occur each year in children 3-11 years of age, according to the CDC.3
Head lice affect people of all socioeconomic classes; they are equal opportunity pests.2,4,5 Infestations tend to be more common in girls, a phenomenon believed to result from their play habits (more head-to-head contact, sharing of combs and brushes and other hair accessories),4 but is not directly related to hair length or frequency of shampooing or brushing.4,6
Prevalence of head lice in African Americans in the US has been notably low. It has been suggested that head lice in this country are not well adapted to grasp the oval-shaped hair shaft that is characteristic of the African American population.4
References: 1. Hodgdon HE, Yoon KS, Previte DJ, et al. Determination of knockdown resistance allele frequencies in global human head louse populations using the serial invasive signal amplification reaction. Pest Manag Sci. 2010;66(9): Frankowski BL, Bocchini JA Jr, American Academy of Pediatrics (AAP) Council on School Health and Committee on Infectious Diseases. Clinical report—head lice. Pediatrics. 2010;126(2): Centers for Disease Control and Prevention (CDC). Head lice. Epidemiology & risk factors. Accessed January 13, Meinking TL, Taplin D, Vicaria M. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011: Meinking TL, Mertz-Rivera K, Villar ME, Bell M. Assessment of the safety and efficacy of three concentrations of topical ivermectin lotion as a treatment for head lice infestation. Int J Dermatol. 2013;52(1): American Academy of Pediatrics. Pediculosis capitis (head lice). In: Red Book Report of the Committee on Infectious Diseases. Pickering LK, ed. 29th ed. Elk Grove Village, IL, American Academy of Pediatrics; 2012: .
References: 1. Hodgdon HE, et al. Pest Manag Sci. 2010;66(9): Frankowski BL, et al. Pediatrics. 2010;126(2): Centers for Disease Control and Prevention (CDC). Head lice. Epidemiology & risk factors. lice/head/epi.html. Accessed January 13, Meinking T, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011: Meinking TL, et al. Int J Dermatol. 2013;52(1): 4

5. Common Myths About Head Lice1
MYTH: Head lice can fly or jump from head to head
FACT: Head lice have no wings and can only crawl.
MYTH: Head lice are a health hazard and are more common in people with poor hygiene.
FACT: Head lice prefer a clean, healthy head; they are not a health hazard and do not transmit disease.
MYTH: Transmission of head lice in the classroom is common.
FACT: Classroom transmission is considered rare.
Common Myths About Head Lice1
In addition to the myths shown on the slide:
Myth: Lice are easy to get.
Fact: Lice are spread primarily by head-to-head contact. They are much harder to get than a cold, flu, ear infection, pink eye, strep throat, or food poisoning.
Myth: Lice are often spread by sharing hats and helmets.
Fact: This is rare but possible. Other uncommon forms of transmission could be hairbrushes, pillows, and sheets.
Myth: Any nits left in the hair can cause lice to come back.
Fact: Any nits farther than ¼ inch to ½ an inch away from the scalp are already hatched or non-viable and pose no risk to others.
Myth: All members of a family should be treated if 1 person in the family has head lice.
Fact: Only persons with evidence of active head lice infestation should be treated.
Reference: 1. Pontius DJ. Hats off to success: changing head lice policy. NASN Sch Nurse. 2011;26(6):
MYTH: You can get head lice from a house pet.
FACT: Dogs, cats, and other house pets do not play a role in head lice transmission.
Reference: 1. Pontius DJ. NASN Sch Nurse. 2011;26(6): 5
CDC. Dr. Dennis D. Juranek.

6. The Head Louse: A Closer Look
The adult louse is 2-3mm long (about the size of a sesame seed)1
Usually pale gray; color may vary1
Red when engorged with blood
May adapt color to surroundings
The louse feeds by injecting small amounts of saliva and taking tiny amounts of blood from the scalp every few hours1
Lice usually survive less than hours away from the scalp at room temperature1,2
Lice that fall off the head are usually dead or dying
Must find a host to survive
Eggs need warm temperatures (like those near the scalp) to hatch
CDC.
The Head Louse: A Closer Look
The adult louse is 2-3mm long, about the size of a sesame seed, and usually pale gray in color, although red when engorged after a blood meal. The louse and its eggs may also change color to adapt to the surroundings—lighter on lighter-colored hair, darker on darker.1
The louse feeds by injecting small amounts of saliva and taking tiny amounts of blood from the scalp every few hours.1 Lice usually survive less than hours away from the scalp at room temperature. 1,2 A louse that falls off the head is probably dead or dying and must find a new host in order to survive. Eggs need a warm ambient temperature, such as that close to the scalp, in order to hatch.1,2
References: 1. Frankowski BL, Bocchini JA Jr, AAP Council on School Health and Committee on Infectious Diseases. Clinical report—head lice. Pediatrics. 2010;126(2): CDC. Head lice. Prevention and control. Accessed March 26, 2013.
References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2): CDC. Head lice. Prevention and control. Accessed March 26, 2013. 6

7. The Life Cycle of the Head Louse1,2
Become adults days after hatching
Female lays 1st egg 1-2 days after mating 3
Lays up to 10 eggs per day
Female lives 3-4 weeks
Without treatment, the cycle may repeat every 3 weeks
Eggs tightly attached to hair, close to scalp
The Life Cycle of the Head Louse
The female louse lays eggs 1 to 2 days after mating and may lay up to 10 eggs per day.1,2 Under ideal laboratory conditions, the female louse can lay as many as 300 eggs in her lifetime.2 A glue-like substance, secreted by glands into the uterus, flows out of the genital opening and attaches the egg firmly to the hair shaft. The glue closely resembles the amino acid composition of the hair shaft and hardens on contact with the air. There is no known solvent.2
Eggs hatch in 7-12 days.1,2 The newly emerged nymph, resembling an adult, is immediately active and highly mobile. Within 30 seconds, it seeks out a suitable host, thrusts its stylets through the skin, and takes its first blood meal. If the first instar nymph does not feed within the first hour after hatching, it will soon die of starvation and desiccation.2
The nymph undergoes 2 more molts before it becomes an adult. The nymph must take a blood meal between each molt, and each instar stage lasts about 3 days. Thus, approximately 9-12 days after hatching, the third instar nymph casts aside its shell and becomes an adult. Mating typically occurs within 24 hours after the third molt but may occur as soon as 10 hours.2
Without treatment, the cycle may repeat itself every 3 weeks.1,2
References: 1. Frankowski BL, Bocchini JA Jr, AAP Council on School Health and Committee on Infectious Diseases. Clinical report—head lice. Pediatrics. 2010;126(2): Meinking TL, Taplin D, Vicaria M. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011: 2
3 nymph stages
Eggs hatch in days 1
Illustration by Penumbra Design Inc.
References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2): Meinking TL, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011: 7

8. Know Your Nits!
Nits are tiny, teardrop-shaped eggs attached to 1 side of the hair shaft with a waterproof, glue-like substance1-4
Often found on nape of the neck and behind the ears5
Viable nits with an egg inside may be tan to coffee-colored or darker1
Nonviable nits are white or yellowish shells, or casings1
Nits attached >1cm from the scalp are usually not viable2
In some warmer climates, viable nits may be found several inches from the scalp3
Close inspection is needed4
CDC/Dr. Dennis D. Juranek.
Nits may be confused with:
Dandruff1-5
Dirt and other debris2,4,5
Droplets of hair spray, gel2-4
Hair casts (pseudonits) encircling the hair shaft1,3,5,6
Plugs of skin cells5
Fungal infection of the hair (piedra)1,3,5
Psoriasis1,3
Know Your Nits!
It is helpful to distinguish viable from nonviable nits.1-6 Nits farther than 1cm from the scalp2 (some authorities use a guideline of ¼ inch4) are usually not viable.2,4
Nits are often mistaken for other entities, including dandruff, dirt particles, droplets of hairspray, and skin cells.1-6 Hair casts or pseudonits are a tube-shaped collection of skin cells that resemble a nit; however, hair casts slide easily off the hair shaft, while nits are quite difficult to remove and are attached to the hair with a glue-like substance.6
References: 1. Meinking TL, Taplin D, Vicaria M. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011: Frankowski BL, Bocchini JA Jr, AAP Council on School Health and Committee on Infectious Diseases. Clinical report—head lice. Pediatrics. 2010;126(2): Paller AS, Mancini AJ, eds. Hurwitz Clinical Pediatric Dermatology. A Textbook of Skin Disorders of Childhood and Adolescence, 4th ed. New York, Elsevier Saunders; 2011: CDC. Head lice. Diagnosis. Accessed January 13, American Academy of Pediatrics. Pediculosis capitis (head lice). In: Red Book Report of the Committee on Infectious Diseases. Pickering LK, ed. 29th ed. Elk Grove Village, IL, American Academy of Pediatrics; 2012: Franca K, Villa RT, Silva IR, de Carvalho CA, Bedin V. Hair casts or pseudonits. Int J Trichol. 2011;3(2):
References: 1. Meinking TL, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011: Frankowski BL, et al. Pediatrics. 2010;126(2): Paller AS, Mancini AJ, eds. Hurwitz Clinical Pediatric Dermatology. A Textbook of Skin Disorders of Childhood and Adolescence, 4th ed. New York, Elsevier Saunders; 2011: CDC. Head lice. Diagnosis. Accessed January 13, American Academy of Pediatrics. Pediculosis capitis (head lice). In: Red Book Report of the Committee on Infectious Diseases. Pickering LK, ed. 29th ed. Elk Grove Village, IL, American Academy of Pediatrics; 2012: Franca K, et al. Int J Trichology. 2011;3(2): 8

9. Head Lice: The Truth About Transmission1-3
Transmission of lice typically occurs by direct head-to-head contact with an infested individual
Children can get head lice anytime they come in close contact with others—during play at home or school, slumber parties, sports activities, or camp
Indirect spread by contact with personal items (combs, brushes, hats, headgear) is less likely but can occur
Getty Images/Jamie Grill.
Head Lice: The Truth About Transmission1-3
Head-to-head contact is the primary means of person-to-person transmission of head lice. Less often, sharing combs, brushes, hats, and other objects may facilitate transmission, especially in warmer climates.
References: 1. Frankowski BL, Bocchini JA Jr, AAP Council on School Health and Committee on Infectious Diseases. Clinical report—head lice. Pediatrics. 2010;126(2): CDC. Head lice. Epidemiology & risk factors. Accessed March 25, Meinking TL, Taplin D, Vicaria M. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011:
References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2): CDC. Head lice. Epidemiology & risk factors. Accessed January 13, Meinking TL, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011: 9

10. Typical Symptoms of Head Lice Infestation
Itching is the most common symptom1-3
Caused by an allergic reaction to louse saliva
If someone is infested for the first time, itching may take 4-6 weeks to develop1
If a person has had previous head lice episodes, itching may develop within 48 hours3
Irritability, difficulty sleeping1
Lice are more active in the dark
Sores, crusting, secondary bacterial infection on the scalp1-3
Not common; caused by excessive scratching
In some cases, no symptoms are present3
Getty Images/Westend61.
Typical Symptoms of Head Lice Infestation
Itching is the telltale symptom of head louse infestation, the result of an allergic reaction to louse bites.1-3 In someone who is infested for the first time, itching typically doesn’t develop for 4-6 weeks1,2; with subsequent infestations, however, itching may occur within 48 hours.3
Lice do not transmit any known disease agent, although secondary bacterial infection can occur as a result of scratching and subsequent excoriation.2 Scratching may lead to impetigo or another skin infection, resulting in local or regional adenopathy.2 Occasionally, areas of excoriation may become superinfected with methicillin-resistant Staphylococcus aureus (MRSA) or streptococcus.4
Photo of scalp is from Gordon SC. Dermatology Nursing. 2010;22(4): Reprinted with permission of the publisher, Jannetti Publications, Inc., Pitman, NJ.
References: 1. CDC. Head lice. Disease. disease.html. Accessed March 28, Frankowski BL, Bocchini JA Jr, AAP Council on School Health and Committee on Infectious Diseases. Clinical report—head lice. Pediatrics. 2010;126(2): Meinking TL, Taplin D, Vicaria M. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011: Lebwohl M, Clark L, Levitt J. Therapy for head lice based on life cycle, resistance, and safety considerations. Pediatrics. 2007;119(5):
Gordon SC. Dermatology Nursing ;22(4): Reprinted with permission of Jannetti Publications, Inc.
References: 1. CDC. Head lice. Disease. Accessed March 28, Frankowski BL, et al. Pediatrics. 2010;126(2): Meinking TL, et al. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011: 10

11. The Key Role of the Clinician in Head Lice Diagnosis and Treatment

12. The Traditional Approach to Head Lice1,a
Head lice suspected 00
70%
of Households
30%
of Households
Treat On Their Own
Contact a Health Care Provider
The Traditional Approach to Head Lice1
Nearly three fourths of households treat cases of head lice on their own, according to recent surveys. Parents will often go straight to the pharmacy, perhaps after turning to a trusted source such as a school nurse. Others may simply call friends or explore the vast reaches of the Internet.
A medical office’s protocol is often to treat over the phone: “Use an over-the-counter (OTC) product first … call back or come in if it doesn’t work.” In situations when a treatment is prescribed, OTC and traditional prescription products are prescribed with roughly equal frequency.
Reference: 1. Sanofi Pasteur Inc., Data on file (ICR Research; Excel Omnibus Studies H , I8823). July MKT26505. .
Desire to avoid delay
Easy access to over-the-counter (OTC) products
Limited parent knowledge of Rx choices
Office may treat “over the phone” by recommending an OTC option or calling in a prescription treatment
a Independent market research conducted in the US; data shown are based on responses from 201 households.
Reference: 1. Sanofi Pasteur Inc., Data on file (ICR Research; Excel Omnibus Studies H , I8823). July MKT26505. 12

13. A New Approach: Getting Clinicians More Involved1
The American Academy of Pediatrics (AAP) calls for a new approach to diagnosis and treatment of head lice
The rationale:
Self-diagnosis by families, plus easy availability of OTC products, have removed clinicians from the treatment process
The potential for misdiagnosis leading to improper use of pediculicides raises concerns about unsafe use of these products, especially when no lice are present or when products are used excessively
Emergence of resistance to some head lice products and introduction of new products call for increased provider involvement in the diagnosis and treatment of head lice
A New Approach: Getting Clinicians More Involved1
In 2010 the AAP, through its Council on School Health and Committee on Infectious Diseases, updated its recommendations on diagnosis and management of head lice. The AAP called on pediatricians and other health care providers to become more directly involved in the decision making process when infestations are detected, noting that resistance to older pediculicide products has spread at the same time that new products are being developed. The Academy feels that practitioners should be better prepared to handle parents’ questions, concerns, and anxieties and that guidance from a clinician would be both timely and welcome.
Reference: 1. Frankowski BL, Bocchini JA Jr, AAP Council on School Health and Committee on Infectious Diseases. Clinical report—head lice. Pediatrics. 2010;126(2):
Reference: 1. Frankowski BL, et al. Pediatrics. 2010;126(2): 13

14. A New Approach: Getting Clinicians More Involved (cont)
According to the AAP, clinicians should:
Be knowledgeable about head lice infestations and the range of treatment options, both OTC and Rx1
Take an active role as information resources for families, schools, and community agencies1
Take time to instruct families in the proper use of head lice products1
The AAP and National Association of School Nurses (NASN) support collaborative efforts to educate communities and develop sensible, evidence-based approaches1,2
A New Approach: Getting Clinicians More Involved (cont)
The clinician’s newly evolving role in head lice management includes being knowledgeable about infestations and the full range of treatment options and serving as an expert information resources for families, schools, fellow health professionals, and the community.1
The clinician also has an important role to play in instructing families in the proper use of head lice products, not only to help ensure successful treatment but also to avoid potentially dangerous misuse and overuse of products.1
Finally, clinicians have an opportunity to collaborate with school nurses and other health care colleagues to educate families, schools, and communities and to assist in the development of sensible, science-based approaches to managing head lice infestations.1,2
References: 1. Frankowski BL, Bocchini JA Jr, AAP Council on School Health and Committee on Infectious Diseases. Clinical report—head lice. Pediatrics. 2010;126(2): Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, Accessed March 28, 2013.
References: 1. Frankowski BA, et al. Pediatrics. 2010;126(2): Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, Accessed March 28, 2013. 14

15. An Alternative to Self-Treatment
School nurse identifies head lice, communicates with family
Treatment successful
Family contacts their health care provider
Treatment unsuccessful
Instruction given on proper use of product
An Alternative to Self-Treatment
As an alternative to self-treatment , families can contact their health care provider when head lice is suspected. The clinician can then confirm the diagnosis, discuss the various treatment options, recommend a course of action, and counsel the family on proper use of the product or products selected. If treatment is not successful, the family can return to their provider to help determine the reasons for failure, which typically include not following treatment instructions, such as lack of adherence or unwillingness to follow the treatment protocol; inadequate treatment, such as not using sufficient product to saturate hair; re-infestation of lice from the household or environment; or resistance of lice to the product used.1 The actual prevalence of resistance to particular products is not known and can be regional.
Reference: 1. Frankowski BL, Bocchini JA Jr, AAP Council on School Health and Committee on Infectious Diseases. Clinical report—head lice. Pediatrics. 2010;126(2):
Diagnosis confirmed by clinician
Rx and OTC options discussed
Treatment choices made 15

16. Who Needs to be Treated?
Treatment should never be initiated without a clear diagnosis of head lice1,2
Definitive diagnosis is made by finding a live louse or nymph on the scalp or head2,3
Misdiagnosis is common3-5
If no nymphs or adults are seen, and the only nits are >1/4 inch from the scalp, infestation is probably old and no longer active3,a
When 1 member of a household is diagnosed, everyone in the household—and other close contacts—should be checked1
Anyone with evidence of active infestation should be treated
All such persons should be treated at the same time
Who Needs to be Treated?
Health authorities generally agree that only persons with active head lice infestation should be treated.1,2 The gold standard for diagnosis is the presence of a live louse or nymph on the scalp or head.2,3 Misdiagnosis is common in part because evidence of head lice can be confused with a variety of other conditions of the hair and scalp.3-5
Members of the household and other close contacts of an infested person should be examined carefully, but only those who have an active infestation need to be treated.1,2
References: 1. CDC. Head lice. Treatment. treatment.html. Accessed March 26, Frankowski BL, Bocchini JA Jr, AAP Council on School Health and Committee on Infectious Diseases. Clinical report—head lice. Pediatrics. 2010;126(2): CDC. Head lice. Diagnosis. Accessed April 4, Pollack RJ, Kiszewski AE, Spielman A. Overdiagnosis and consequent mismanagement of head louse infestations in North America. Pediatr Infect Dis J. 2000;19(8): Burkhart CG. Relationship of treatment-resistant head lice to the safety and efficacy of pediculicides. Mayo Clin Proc. 2004;79(5):
a Some authorities use a guideline of >1cm from the scalp.2
References: 1. CDC. Head lice. Treatment. Accessed March 26, Frankowski BL, et al. Pediatrics. 2010;126(2): CDC. Head lice. Diagnosis. diagnosis.html. Accessed April 4, Pollack RJ, et al. Pediatr Infect Dis J. 2000;19(8): Burkhart CG. Mayo Clin Proc. 2004;79(5): 16

17. Guidance on Managing Infestations
In recommending treatment, the clinician should consider the product’s:1
Effectiveness
Safety
Ease of use
Cost
Local patterns of resistance (if known)
There is no scientific evidence that home remedies are effective1,2
Remedies not based in science can be expensive and frustrating, leaving the child and family ineffectively treated
Treatment recommendations should be evidence-based and come from medical, public health, and nursing experts rather than anecdotal experience or commercial advertisements3
Guidance on Managing Infestations
The AAP advises clinicians to take several factors into consideration in recommending treatments for head lice, including the product’s effectiveness, safety profile, ease and convenience of use, cost, and local patterns if resistance, if known.1
Home remedies are not supported by scientific evidence and may delay effective treatment.1,2 Treatment recommendations for pediculosis should be based on evidence-based reports from medical, public health, and nursing content experts and not on anecdotal experience or commercial advertisements.3
References: 1. Frankowski BL, Bocchini JA Jr, AAP Council on School Health and Committee on Infectious Diseases. Clinical report—head lice. Pediatrics. 2010;126(2): Takano-Lee M, Edman J, Mullens B, Clark J. Home remedies to control head lice: assessment of home remedies to control the human head louse, pediculus humanus capitis. J Pediatr Nurs. 2004;19(6): Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, Accessed March 28, 2013.
References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2): Takano-Lee M, et al. J Pediatr Nurs. 2004;19(6): Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, Accessed March 28, 2013. 17

18. Guidance on Managing Infestations (cont)
Resistance to some head lice products has been reported, but the prevalence is not known1
According to the AAP, 1% permethrin or pyrethrins (OTC products) can be used to treat active infestations—unless resistance has been noted in the community1
If a treatment does not seem to be working, possible causes include incorrect use of the product or resistance2
Newer prescription treatment options are available to help families resolve head lice episodes
Guidance on Managing Infestations (cont)
Resistance to some head lice products has been reported, but the prevalence is not known.1 The AAP notes that OTC products such as 1% permethrin or pyrethrins can be tried initially to treat active head lice infestations—unless resistance has been noted in the community.1
If a treatment does not seem to be working, possible causes include incorrect use of the product or resistance.2 Public health departments, medical centers, and teaching institutions in the area may have information on resistance patterns within specific communities or regions. Meanwhile, newer Rx treatment options are available to help families resolve head lice episodes.
References: 1. Frankowski BL, Bocchini JA Jr, AAP Council on School Health and Committee on Infectious Diseases. Clinical report—head lice. Pediatrics. 2010;126(2): CDC. Head lice. Treatment. Accessed March 28, 2013.
References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2): CDC. Head lice. Treatment. Accessed March 28, 2013. 18

19. Careful Instruction: Key to Avoiding Misuse, Overuse
The clinician should offer families careful instruction in the proper use of head lice products1
Need for second treatment? Use of nit comb?
Products vary; families should be advised to follow the specific instructions that accompany the product
Parents should not use extra amounts of any lice medication unless instructed to do so by their health care provider2
Drugs used to treat head lice can be dangerous if misused or overused
An infested person should not be treated more than 2-3 times with the same medication if it does not seem to be working2
In such situations, it is important to seek the advice of a health care provider, who may recommend an alternative medication
Getty Images/Photodisc.
Careful Instruction: Key to Avoiding Misuse, Overuse1,2
References: 1. Frankowski BL, Bocchini JA Jr, AAP Council on School Health and Committee on Infectious Diseases. Clinical report—head lice. Pediatrics. 2010;126(2): CDC. Head lice. Treatment. Accessed March 28, 2013.
References: 1. Frankowski BL, et al. Pediatrics. 2010;126(2): CDC. Head lice. Treatment. Accessed March 28, 2013. 19

20. Cleaning Up: What’s Really Needed?1
Use of pediculicides is part of an overall approach to head lice management that may also include:
Wash in hot water or dry-clean all clothing, hats, bed linens, and towels used by an infested person during the 2 days prior to treatment
Wash personal care items such as combs, brushes, and hair clips in hot water
Vacuum floors and furniture, especially where the infested person sat or lay
Fumigant sprays or fogs are not needed to control head lice
These products can be toxic if inhaled or absorbed through the skin
Shutterstock.
Cleaning Up: What’s Really Needed?1
Reference: 1. CDC. Head lice. Prevention & control. prevent.html. Accessed March 26, 2013.
Photos.com.
Reference: 1. CDC. Head lice. Prevention & control. Accessed March 26, 2013. 20

21. The School Nurse’s Pivotal Roles in Head Lice Management

22. The School Nurse: First Responder to Head Lice Infestation
School nurses are often the first to assess a child for the presence of head lice1
The NASN encourages parents to talk to their school nurse about head lice
When a case of head lice is suspected, school nurses should
Provide accurate information to families and
Encourage them to contact their physician or other health care provider to confirm the diagnosis and discuss treatment options
The School Nurse: First Responder to Head Lice Infestation1
The school nurse is often the first person to detect a head lice infestation or to assess a student for the possibility. As such, the nurse is in a unique position to help manage the situation—for the student, the family, the classroom, and the school—in a way that minimizes disruption and ensures prompt and effective treatment. The NASN encourages conversations between parents and their school nurse on this sensitive matter and a host of other health issues.
When head lice is suspected, the school nurse can advise the family to contact their health care provider in order to confirm the diagnosis and review treatment options. School nurses can partner with health care providers in this effort by making sure the family has the information and resources it needs to respond appropriately to a head lice incident.
Reference: 1. Schoessler SZ. Treating and managing head lice: the school nurse perspective. Am J Manag Care. 2004;10(9 Suppl):S273-S276.
Reference: 1. Schoessler SZ. Am J Manag Care. 2004;10(9 Suppl):S273-S276. 22

23. The School Nurse: Educator
School nurses play an essential role in educating families, teachers, and school officials about head lice1
Calming fears
Dispelling myths and stigmas regarding pediculosis
Maintaining student privacy and confidentiality
Building awareness of effective head lice management
“School nurses are 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 to the student’s family, school, and community at large.” —NASN1
The School Nurse: Educator1
School nurses have opportunities to educate virtually everyone affected by a head lice outbreak—students, parents, teachers, principals, administrators, school boards, and the community at large. School nurses possess a unique and valuable combination—access to scientific information and the opportunity to put that information to use in teachable moments.
Reference: 1. Pontius D, Teskey C. Pediculosis management in the school setting. National Association of School Nurses (NASN) position statement, Accessed March 28, 2013.
Reference: 1. Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, Accessed March 28, 2013. 23

24. The School Nurse: Advocate
School district policies on head lice management vary widely1-3
Not always based on science
School nurses can be instrumental in championing evidence-based policies in their school districts and communities1-5
Getty Images/Ariel Skelley.
The School Nurse: Advocate1-5
The NASN also views school nurses as ideal champions for evidence-based approaches to head lice management. They know the science, they can communicate the science, and thus they are in strategic position to communicate an educated point of view. Later in this presentation, we’ll cite specific examples of school nurses who were highly successful in this role.
References: 1. Weisberg L. The goal of evidence-based pediculosis guidelines. Nasnewsletter. 2009;24(4): Sciscione P, Krause-Parello CA. No-nit policies in schools: time for change. J School Nurs. 2007;23(1): Pontius DJ. Hats off to success—changing head lice policies. NASN Sch Nurse. 2011;36(6): Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, Accessed March 28, Schoessler SZ. Treating and managing head lice: the school nurse perspective. Am J Manag Care. 2004;10(9 Suppl): S273-S276.
“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.”4
References: 1. Weisberg L. Nasnewsletter. 2009;24(4): Sciscione P, et al. J Sch Nurs. 2007;23(1): Pontius DJ. NASN Sch Nurse. 2011;36(6): Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, Accessed March 28, Schoessler SZ. Am J Manag Care. 2004;10(9 Suppl):S273-S276. 24

25. The School Nurse: First Responder, Educator, Advocate
The school nurse thus has a vital role to play in:
Facilitating an accurate assessment of the problem1,2
Containing head lice infestations1,2
Safeguarding family privacy and confidentiality1,2
Advising affected students and families to contact their physician or other health care provider to discuss available treatment options3
Preventing overexposure to potentially hazardous chemicals1,2
Minimizing school absences1,2
The School Nurse: First Responder, Educator, Advocate
The school nurse can contribute to positive outcomes in many ways—not only by helping to control head lice infestations but also by protecting the student’s and family’s privacy, offering tips on prevention for future reference, and enabling students to avoid missed school days.1,2 School nurses can also help coordinate care by advising families to contact their health care provider, who can discuss and recommend treatment options, offer instruction on appropriate use of products, and both guide and evaluate the course of care.3
References: 1. Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, Accessed March 28, Schoessler SZ. Treating and managing head lice: the school nurse perspective. Am J Manag Care. 2004;10(9 Suppl):S273-S276.
3. Burkhart CG. Relationship of treatment-resistant head lice to the safety and efficacy of pediculicides. Mayo Clin Proc. 2004;79(5):
References: 1. Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, Accessed March 28, Schoessler SZ. Am J Manag Care. 2004;10(9 Suppl):S273-S Burkhart CG. Mayo Clin Proc. 2004;79(5): 25

26. Strategies for School: When Lice Go to the Head of the Class

27. Managing Infestations in the School: NASN Guidance
If a child in school has live head lice, he or she should remain in class but be discouraged from close direct head contact with others
The school nurse should contact the parents to discuss treating the child at the end of the school day
It is vital to prevent stigmatizing and maintain the student’s privacy and the family’s right to confidentiality
It may be appropriate to screen others who have had close head-to-head contact with a student who has an active infestation
Classroom-wide or school-wide screening is not merited
Students with nits only should not be excluded from school; however, it is appropriate to monitor for signs of active re-infestation
Managing Infestations in the School: NASN Guidance1
The NASN guidance on management of pediculosis in schools, issued in 2011, sets forth a step-by-step procedure for nurses to follow when a case of head lice is reported during the school day.
Reference: 1. Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, Accessed March 26, 2013.
Reference: 1. Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, Accessed March 26, 2013. 27

28. Helping Kids Stay in School
The AAP and NASN state: No healthy child should be allowed to miss school time because of head lice1,2
“No-nit” policies for return to school should be abandoned1,2
School-based head lice screening programs have not had a significant effect on incidence of head lice in schools and are not cost-effective2
Helping Kids Stay in School
According to the AAP and the NASN, students with nits but no live lice should not be excluded from school, although monitoring of the child is appropriate.1,2 In 1 study of 1729 schoolchildren screened and observed for 14 days, only 9 of 50 children who had nits alone developed a head louse infestation.3
The American School Health Association has also taken a stand against no-nit policies, noting that such policies and practices “are not effective in controlling lice outbreaks and may be disruptive to the education process.”4
School-based head lice screening programs have not had a significant effect on incidence of head lice in schools and are not considered cost-effective.2 School nurses, according to the NASN, are in a “pivotal position” to dispel myths and stigmas about pediculosis by providing education to the family, the school, and the community at large and by reassuring children that head lice are not associated with poor hygiene.1
References: 1. Pontius D, Teskey C. Pediculosis management in the school setting. Position statement, NASN, Accessed January 13, Frankowski BL, Bocchini JA Jr, AAP Council on School Health and Committee on Infectious Diseases. Clinical report—head lice. Pediatrics. 2010;126(2): Williams LK, Reichert A, MacKenzie WR, et al. Lice, nits, and school policy. Pediatrics. 2001;107(5): American School Health Association. School policies in the management of pediculosis (head lice). Pediculosis.pdf. Accessed January 13, 2013.
iStockphoto.
References: 1. Pontius D, Teskey C. Pediculosis management in the school setting. NASN position statement, Accessed January 13, Frankowski BL, et al. Pediatrics. 2010;126(2): 28

29. Easing the Stigma
Head lice infestations can take a high emotional and psychological toll on some children and parents1-3 People with head lice may feel:
Disgust, horror, panic, anger; feelings of being dirty or contaminated
Excluded from school and social activities
Head lice infestations can be an emotional issue in schools
Parents may panic when they are told their child has head lice
Students may feel isolated
Parents should rely on the experience and judgment of school nurses and other health professionals who are equipped to provide accurate information and recommend or prescribe treatment options
Easing the Stigma
Although head lice are not regarded as a serious threat to physical health, infestations take a sizeable toll, both psychologically and in their economic impact. Children and their families may be ostracized, ridiculed, and made to feel “dirty” when infestations develop. Children are excluded from school by formal no-nit policies and from social activities by the informal and often cruel manifestos of the playground.1-3
In families where children have persistent infestation, parents report social ostracism, some of it self-imposed; being blamed by health care providers for not treating the child properly; and “trying everything”—including ineffective and unsafe measures such as dog shampoo—in a desperate effort to eliminate the problem.1
References: 1. Gordon SC. Shared vulnerability: a theory of caring for children with persistent head lice. J School Nurs. 2007;23(5): Parison J, Speare R, Canyon DV. Head lice: the feelings people have. Int J Dermatol. 2013;52(2): Parison J, Canyon DV. Head lice and the impact of knowledge, attitudes and practices—a social science overview. In: Heukelbach J, ed. Management and Control of Head Lice Infestations. UNI-MED, Bremen, Germany; 2010:
References: 1. Gordon SC. J School Nurs. 2007;23(5): Parison J, et al. Int J Dermatol. 2013;52(2): Parison J, Canyon DV. Head lice and the impact of knowledge, attitudes and practices—a social science overview. In: Heukelbach J, ed. Management and Control of Head Lice Infestations. UNI-MED, Bremen, Germany; 2010: 29

30. Supporting Families
The school nurse can help students and families cope with the anxiety and stress of head lice episodes1,2
The nurse has an opportunity to establish ongoing relationships with students and families
Often perceived as an ally
Offer support and encouragement through:
Fact-to-face conversations with families
Frequent phone contact
Written materials sent home with the student
Nurse can serve as case manager
Educating families and providing helpful resources for dealing with infestations
Directing them to their physician or other health care provider to discuss treatment options
Following up with families
Supporting Families1,2
The school nurse is in a unique position to be helpful to families who are coping with head lice infestations and their aftermath. In addition to providing case management, the school nurse can offer support and encouragement as a trusted ally during a time of stress and anxiety, as well as education that will be beneficial in the long run.
References: 1. Gordon SC. Shared vulnerability: a theory of caring for children with persistent head lice. J School Nurs. 2007;23(5): Schoessler SZ. Treating and managing head lice: the school nurse perspective. Am J Manag Care. 2004;10(9bSuppl):S273-S276.
References: 1. Gordon SC. J School Nurs. 2007;23(5): Schoessler SZ. Am J Manag Care. 2004;10(9 Suppl):S273-S276. 30

31. The School Nurse: Champion for Evidence-Based Policies
“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.” —NASN
School nurses can be successful in persuading school districts to adopt evidence-based approaches:1-4
Case in point: Lovelock, Nevada2
School nurse used incremental approach to achieve change
Individual conversations with teachers, administrators
“Lice 101” presentation to school board
Educational letters to parents; fact sheets on myths
Case in point: 5 school districts in an Iowa county3
School nurses were called upon to serve as “catalysts for change”
Disseminated information on evidence-based approaches to key stakeholders
Helped develop pediculosis toolkit—“best practice guideline” rather than “policy”
Enlisted local public health department as a key partner
The School Nurse: Champion for Evidence-Based Policies
The NASN encourages school nurses to become involved in community-wide efforts
to adopt science-based approaches to the management of head lice infestations.1
The examples cited on this slide and the next are success stories from school nurses who assembled the evidence and were persuasive in convincing school boards to abandon no-nit policies and other restrictive measures.2-4
In both scenarios, one in Nevada and another in Iowa, the school nurse networked with colleagues and stakeholders, developed educational materials to share with families as well as school officials, and invested the time needed to meet with the decision makers.2,3 The result: nurses as “expert witnesses” on head lice were successful in making others aware of the evidence, helped build consensus, and reassured policy makers that they were doing the right thing.
References: 1. Pontius D, Teskey C. Pediculosis management in the school setting. Position statement, NASN, Accessed March 28, Pontius DJ. Hats off to success: changing head lice policy. NASN Sch Nurse. 2011;26(6): Andresen K, McCarthy AM. A policy change strategy for head lice management. J Sch Nurs. 2009;25(6): Weisberg L. The goal of evidence-based pediculosis guidelines. Nasnewsletter. 2009;24(4):
Getty Images/joSon.
References: 1. Pontius D, Teskey C. Pediculosis management in the school setting. Position statement, NASN, Accessed March 28, Pontius DJ. NASN Sch Nurse. 2011;26(6): Andresen K, McCarthy AM. J Sch Nurs. 2009;25(6): Weisberg L. Nasnewsletter. 2009;24(4): 31

32. Summary
School nurses are important first responders to head lice infestations
They play a key strategic role in supporting children and families, ensuring privacy, and combating myths and stigma associated with head lice
School nurses can work collaboratively with parents, physicians, and other health care providers to help manage head lice outbreaks in a calm and professional manner
Summary 32

33. Summary (cont)
School nurses can help their communities by advocating for evidence-based policies and encouraging an end to no-nit policies for school re-entry
Professional associations such as the AAP are urging pediatricians and other clinicians to become more involved in head lice management and family education
School nurses can support the AAP guidance by directing students and families to first contact their physician to discuss treatment options
Summary (cont) 33

34. For More Information …
Visit the Lice Lessons resources area at
Selected References
NASN. Pediculosis management in the school setting, 2011 NASN position statement.
Pontius DJ. Hats off to success: changing head lice policy. NASN Sch Nurse. 2011;26(6):
Frankowski BL, Bocchini JA Jr, AAP Council on School Health and Committee on Infectious Diseases. Clinical report—head lice. Pediatrics. 2010;126(2):
Weisberg L. The goal of evidence-based pediculosis guidelines. Nasnewsletter. 2009;24(4):
Gordon SC. Shared vulnerability: a theory of caring for children with persistent head lice. J School Nurs. 2007;23(5):
Andresen K, McCarthy AM. A policy change strategy for head lice management. J Sch Nurs. 2009;25(6):
For More Information ... 34

35. Background Information on Approved Head Lice Products

36. Treating Head Lice: Many Choices
OTC
Prescription
Nix®,a (permethrin, 1%)
Lindanec 1% shampoo
RID®,b et al (pyrethrins with piperonyl butoxide)
Ovide®,d (malathion, 0.5% lotion)
Ulesfia®,e (benzyl alcohol, 5% lotion)
Natroba®,f (spinosad, 0.9% suspension)
Sklice®,g (ivermectin, 0.5% lotion)
Treating Head Lice: Many Choices
Treatments for head lice that are approved by the US Food and Drug Administration include both OTC products (permethrin, pyrethrins) and prescription drugs. Prescription products approved for treatment of head lice include 1% lindane shampoo,1 0.5% malathion lotion (Ovide),2 5% benzyl alcohol lotion (Ulesfia),3 0.9% spinosad suspension (Natroba),4 and 0.5% ivermectin lotion (Sklice).5
References: 1. Lindane [Prescribing Information]. Morton Grove, IL: Morton Grove Pharmaceuticals; Ovide [Prescribing Information]. Hawthorne, NY: Taro Pharmaceuticals; Ulesfia [Prescribing Information]. Florham Park, NJ: Shionogi Inc.; Natroba [Prescribing Information]. Carmel, IN: ParaPRO LLC; Sklice Lotion [Prescribing Information]. Swiftwater, PA: Sanofi Pasteur Inc.; 2012.
Important Safety Information for Sklice Lotion The most common adverse reactions for Sklice (<1%) are conjunctivitis, ocular hyperemia, eye irritation, dandruff, dry skin, and skin burning sensation.
Please see Important Safety Information for Sklice Lotion at the end of this presentation. Full Prescribing Information for Sklice Lotion will be provided at this session.
a Nix® is a registered trademark of Insight Pharmaceuticals, LLC. b RID® is a registered trademark of Bayer HealthCare, LLC. c Lindane is manufactured by Morton Grove Pharmaceuticals. d Ovide® is a registered trademark of Taro Pharmaceuticals, U.S.A., Inc. e Ulesfia® is a registered trademark of Shionogi, Inc. f Natroba® is a registered trademark of ParaPRO LLC. g Sklice Lotion® is a registered trademark of Sanofi Pasteur Inc. 36

37. Prescription Lice Products
Lindane, 1%1
Malathion, 0.5%
(Ovide)2
Benzyl alcohol, 5% (Ulesfia)3
Spinosad, 0.9% (Natroba)4
Ivermectin, 0.5%
(Sklice Lotion)5
Age indication
Use with caution in those <110lb
Safety not shown <6 y
≥6 mo
≥4 y
Dosage
1-2oz depending on hair length and density
2-oz bottles; apply enough to wet hair and scalp
4-48oz (varies with hair length)
Up to 120mL (1 bottle) depending on hair length
Up to 120mL ( 4-oz tube)
Time of application
4 min; do not re-treat
8–12 hr; repeat
treatment in 7-9 d if lice present
10 min; repeat treatment after 7 d
10 min; repeat treatment in 7 d if lice present
10 min; tube is intended for single use only; consult health care provider prior to re-treatment
Prescription Lice Products
Prescription lice products have varying age indications, recommended dosages, and time of application, underscoring the importance of following instructions carefully. The Prescribing Information for the products listed in the table1-5 provides the following information on the use of nit combs and other components of head lice management.
Ulesfia3, Natroba4, and Sklice Lotion5: The Prescribing Information for these products, under the heading “Adjunctive Measures,” recommends that the products be used in the context of an overall lice management program that includes:
Wash in hot water or dry-clean all recently worn clothing, hats, used bedding, and towels;
Wash personal care items such as combs, brushes, and hair clips in hot water;
A fine-tooth comb or special nit comb may be used to remove dead lice and nits.
Ovide2: In the Prescribing Information, Step 10 in “Information to Patients” is “Rinse hair and use a fine-toothed nit comb to remove dead lice and eggs.”
Lindane1: The Prescribing Information recommends “Manual removal of nits using a comb designed for this purpose and/or individual removal with tweezers followed by close examination of the hair and scalp.”
References: 1. Lindane [Prescribing Information]. Morton Grove, IL: Morton Grove Pharmaceuticals; Ovide [Prescribing Information]. Hawthorne, NY: Taro Pharmaceuticals, Ulesfia [Prescribing Information]. Florham Park, NJ: Shionogi Inc., Natroba [Prescribing Information]. Carmel, IN: ParaPRO LLC; Sklice Lotion [Prescribing Information]. Swiftwater, PA: Sanofi Pasteur Inc.; 2012.
The comparison of product information has not been established in head-to-head trials.
The clinical significance of this information has not been established.
Please see Important Safety Information for Sklice Lotion at the end of this presentation.
Full Prescribing Information for Sklice Lotion will be provided at this session.
References: 1. Lindane [Prescribing Information]. Morton Grove, IL: Morton Grove Pharmaceuticals; Ovide [Prescribing Information]. Hawthorne, NY: Taro Pharmaceuticals; Ulesfia [Prescribing Information]. Florham Park, NJ: Shionogi Inc.; Natroba [Prescribing Information]. Carmel, IN:ParaPRO, Sklice Lotion [Prescribing Information]. Swiftwater, PA: Sanofi Pasteur Inc.; 2012. 37

38. Important Safety Information for Sklice Lotion
Indication Sklice Lotion is a pediculicide indicated for the topical treatment of head lice infestations in patients 6 months of age and older. Adjunctive Measures Sklice Lotion should be used in the context of an overall lice management program: Wash (in hot water) or dry clean all recently worn clothing, hats, used bedding and towels. Wash personal care items such as combs, brushes and hair clips in hot water. A fine tooth comb or special nit comb may be used to remove dead lice and nits. Important Safety Information for Sklice Lotion In order to prevent accidental ingestion, Sklice Lotion should only be administered to pediatric patients under the direct supervision of an adult. The most common adverse reactions (incidence <1%) were conjunctivitis, ocular hyperemia, eye irritation, dandruff, dry skin, and skin burning sensation. Before administering Sklice Lotion, please see the full Prescribing Information provided at this session.
Important Safety Information for Sklice Lotion
Indication
Sklice Lotion is a pediculicide indicated for the topical treatment of head lice infestations in patients 6 months of age and older.
Adjunctive Measures Sklice Lotion should be used in the context of an overall lice management program:
Wash (in hot water) or dry clean all recently worn clothing, hats, used bedding and towels.
Wash personal care items such as combs, brushes and hair clips in hot water.
A fine tooth comb or special nit comb may be used to remove dead lice and nits.
In order to prevent accidental ingestion, Sklice Lotion should only be administered to pediatric patients under the direct supervision of an adult.
The most common adverse reactions (incidence <1%) were conjunctivitis, ocular hyperemia, eye irritation, dandruff, dry skin, and skin burning sensation
Before administering Sklice Lotion, please see the full Prescribing Information provided at this session. 38