1. An Overview for Parents, Teachers, & Communities
Head Lice 101
Presenter Instructions: This presentation is for use at meetings (for example, PTA meetings or Staff Meetings) to educate child caregivers, including parents, teachers, and nurses, about head lice treatment. If attendees are interested in learning more, there are several downloadable resources available at NASN.org.
An Overview for Parents, Teachers, & Communities

2. Head Lice Fast Facts Head lice are a common community issue
In the United States, an estimated 6 to 12 million lice infestations occur each year among children aged 3 to 111
Children can get head lice anytime they are in close contact with others – for example, during play at home or school, slumber parties, sports activities or camp
Head lice are wingless insects
They live close to the scalp and feed on human blood
They are not dangerous and do not transmit disease but are easily spread1
School nurses are often the first to detect head lice
If head lice is suspected, it is important for families to talk to their healthcare provider
Presenter Instructions:
This slide is a primer for the rest of the Head Lice 101 presentation. Please read through the bullets with your audience.
Additional Information:
Head lice are a common community issue:
At any point, 1-3% of children in elementary schools of industrialized nations may have head lice. During an outbreak, this number may be as high as 25%.1
Head lice affect people of all ages without regard to socioeconomic status or ethnic group. However, in the US, head lice are much less common among African Americans than people of any other races or ethnic groups.2,3
Head lice are found on clean and healthy hosts and tend to prefer clean hair.3
Head lice are wingless insects:
While many are fearful that they can get lice from simply being around someone who is infected, that is not the case. The most common method of transmission of head lice is by direct contact with the head of a person who is already infested.5
Head-to-head contact and close body contact are common among preschool and elementary-aged children, which may explain why children in this age range (3-12 years of age) are most commonly affected by head lice.3,4,6
School nurses are often the first to detect head lice:
The gold standard for diagnosing a head lice infestation is by direct identification of a crawling, live adult louse or nymph in the hair, on the scalp or back of the neck, or on hair behind the ears.7,8
While school nurses are often the first to detect head lice, that does not necessarily mean that the child came into contact with lice at school.
Presenter Notes References:
Roberts RJ. Head lice. N Engl J Med. 2002;346(21):
Gordon S. Shared vulnerability: a theory of caring for children with persistent head lice. J School Nursing. 2007;23(5):
Meinking T, Taplin D, Vicaria M. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011:
Burkhart CG. Relationship of treatment-resistant head lice to the safety and efficacy of pediculicides. Mayo Clin Proc. 2004;79:
Frankowski BL, Bocchini JA, Jr, Council on School Health and Committee on Infectious Diseases. Head lice. Pediatrics. 2010;126:
CDC. Lice – Head Lice. Epidemiology & Risk Factors. CDC website. September 24, 2013.
CDC. Lice – Head Lice. Diagnosis. CDC website. September 24, 2013.
Hansen RC, O’Haver J. Economic considerations associated with Pediculus humanus capitis infestation. Clinical Pediatrics. 2004;43:

3. What Are Head Lice?
Head lice are tiny, wingless insects that live close to the human scalp. When checking a student for head lice, you may see several forms:1
Nits (eggs)
Teardrop shaped
Attached to the hair shaft
Yellowish or white
Can be confused with dandruff but cannot be brushed off
Nymph (baby louse)
Grows to adult size in one to two weeks
Found on the scalp or in the hair
Adult louse
Size of a sesame seed
Tan to grayish-white
Commonly behind the ears and near the neckline
Nit
Nymph
Presenter Instructions:
This slide is to help your audience identify a louse when they are searching their child or student’s head.
Additional Information:
Nits/Eggs
The egg is typically attached close to the scalp and the eggs are incubated by the body heat of the host.1
Eggs typically hatch in 8-9 days depending on the ambient temperature.2
The idea temperature for incubation is 82-90°F with 70-90% relative humidity.2
Without a human scalp to provide warmth, the egg may not hatch at room temperature.1
Nymph
When the louse hatches from the egg, it is called a nymph. The empty egg casing (called a nit) will remain in the hair.1
If the nymph does not feed within 1 hour of hatching from the egg, it will die.2
It takes approximately 9-12 days after hatching for the nymph to become an adult.1,2
Adult
The adult female louse lays eggs from 3-10 times a day.2
A female louse can lay eggs over an average lifetime.3
The average lifetime of an adult is approximately 16 days.3
Adults can survive for a maximum of 30 days.4
Without a human host to provide a blood meal, adult lice will survive for about 1-3 days at room temperature.1,4
Presenter Notes References:
Frankowski BL, Bocchini JA, Jr, Council on School Health and Committee on Infectious Diseases. Head lice. Pediatrics. 2010;126:
Meinking T, Taplin D, Vicaria M. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011:
Ko CJ, Elston DM. Pediculosis. J Am Acad Dermatol. 2004;50:1-12.
Jones KN, English JC. Review of common therapeutic options in the United States for the treatment of pediculosis capitis. Clinical Infectious Diseases. 2003; 36:1355–1361.
Louse

4. Who and How? Who gets head lice? How do head lice spread?
Most often spread by direct head-to-head contact1
Head lice cannot jump or fly1
They cannot live off the head for long, so it is uncommon to spread head lice by contact with clothing or other personal items1
Dogs, cats and other pets do not play a role in spreading head lice1
Who gets head lice?
Almost anyone can get head lice
Head lice are not a health hazard or sign of poor hygiene2
Children attending preschool or elementary school, and those who live with them, are the most commonly affected1
Presenter Information:
This slide is useful to review with the audience as a reminder that head lice can affect anyone, of all ages, genders, races and ethnicities, and socioeconomic status.
Please remind your audience that head lice prefer clean, healthy hair; it is a myth that only dirty children get head lice!
Additional Information:
Who gets head lice?
While people of all ages are susceptible to head lice, infestations are mostly a common problem for children. Head lice are often found in children 3-12 years of age and their family members, household members, or caretakers.1
In one study it was found that approximately 1.2 million households are affected by lice annually; this amounts to 8% of all school-aged children. However, the CDC reports that reliable data on the number of infestations that occur every year are not available because head lice cases are not reported on a state or national level.2
Some surveys show that head lice infestations are more common in girls than in boys. This could be due to sharing brushes, hair accessories, combs, etc. Hair length, brushing or shampooing frequency does not affect the rate of head lice infestation.3
How do head lice spread?
While it is useful to remember that the most common way to spread head lice is through direct head-to-head contact, it is also important to note that head lice can also be potentially spread through the sharing of fomites, or inanimate objects. This type of indirect transmission is less common than transmission through direct contact, however head lice may cling to and survive on fomites for 1-2 days.3,4,5
The items that can transmit head lice by indirect contact include clothing (hat, scarf, sports uniform), personal items (like combs, brushes, hair ribbons), bedding or textiles (couch, carpet, towels, car seat, pillow, stuffed animal), sporting gear (helmets), or head phones (in the school computer lab).3,4
Presenter Notes References:
Burkhart CG. Relationship of treatment-resistant head lice to the safety and efficacy of pediculicides. Mayo Clin Proc. 2004;79:
Clark JM, Lee SH, Yoon KS, Strycharz JP, Kwon DH. Chapter 6. Human head lice: status, control and resistance. In: Clark JM, Bloomquist JR, Kawada H, eds. Advances in Human Vector Control. Washington, DC: American Chemical Society; 2009:73-88.
Meinking T, Taplin D, Vicaria M. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011:
CDC. Lice – Head Lice. Epidemiology & Risk Factors. CDC website. September 24, 2013.
CDC. Lice – Head Lice. Resources for Health Professionals. CDC website. April 20, 2015.

5. Is It Head Lice?
Some people don’t experience symptoms, but those who do most commonly experience:1
Tickling feeling on the scalp or in the hair
Itching (caused by the bites of the louse)
Irritability and difficulty sleeping (lice are more active in the dark)
Sores on the head (caused by scratching)
Finding a live louse is the best indication of an infestation.3
- Look for nits close to the scalp; lice are most commonly found behind the ears and near the neckline at the back of the head.
Presenter Information:
Because head lice infestations are most commonly diagnosed at school, it is important for school nurses and schoolteachers to recognize the signs and symptoms of an active infestation.
Additional Information:
Signs and Symptoms:
Signs of a head lice infestation are characteristics that can be easily observed. Skin irritation is the main sign associated with infestation and common signs include redness, scaling, abrasion of the skin along the hairline, small red flat rash, sores on the head caused by scratching.1
Symptoms of an active infestation are listed on the slide and are typically reported by the patient.
Diagnosis:
Again, finding a live louse is the gold standard for diagnosing a head lice infestation.2,3
Head lice and nits are visible to the naked eye, but you may have difficulty spotting one. They are often challenging to find because they are very small, move quickly, and avoid light.4
It may be useful to use a magnifying glass to observe crawling lice or to distinguish a viable egg from an empty egg case.1,2
Newly laid eggs may be tan to coffee-colored or darker, with the cap of the egg always facing away from the scalp.1
Finding eggs cemented to the hair shaft within a ¼ inch (4 mm) from the scalp suggests the eggs are viable, but does not confirm that the person has an active head lice infestation.2,4
Keep in mind that the small, oval shape of a nit can be confused easily with other particles in the hair including dandruff, hair spray droplets, scabs, other insects, insect bites, eczema, psoriasis, dermatitis, and dirt or debris. However, a unique feature of the egg is that they are firmly attached and difficult to remove from the hair shaft.1,2,4
Presenter Notes References:
Meinking T, Taplin D, Vicaria M. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011:
CDC. Lice – Head Lice. Diagnosis. CDC website. September 24, 2013.
Diamantis SA, Morrell DS, Burkhart CN. Treatment of head lice. Dermatologic Therapy. 2009;22:273–278.
Frankowski BL, Bocchini JA, Jr, Council on School Health and Committee on Infectious Diseases. Head lice. Pediatrics. 2010;126:

6. I Identified a Live Louse. What Next?
5 Steps For Parents: How to Manage an Active Head Lice Infestation
If head lice are suspected, families should consult with a healthcare provider as soon as possible
Key treatment considerations include:
Resistance to some over-the-counter (OTC) head lice treatments has been reported, but the prevalence is not known2
There is no scientific evidence that home remedies are effective4
There are prescription treatment options available – caregivers should contact their child’s healthcare professional to determine what is appropriate for them
Check the whole family for head lice.
Anyone with evidence of an active lice infestation should be treated, and all persons with active head lice should be treated at the same time.5
See your healthcare provider.
Clean to remove lice from your house.
Share the info with your child’s school and the parents of other children your child may have come into contact with.
Presenter Information:
Parents will often have questions after a head lice diagnosis has been confirmed. It is important for school nurses to understand how to counsel parents in the next steps of fighting an active infestation. Additionally, parents and health care providers should be aware of the treatment options that are available to them so they can make their best judgement on what is right for their child. Involving a health care provider in the treatment plan is a great first step to take.
Additional Information:
All persons diagnosed with head lice should be treated, and treatment should NOT be initiated unless the diagnosis of head lice is clear. Treating head lice “proactively” without identifying a live louse first only contributes to the emergence of treatment-resistant lice. Universal prophylactic use of pediculicides should be discouraged and may be potentially harmful to a person who does not have a head lice infestation.1,2
If treating several members of the family at the same time, treatment should occur simultaneously.3
Treatment options include over-the-counter products, manual nit removal with a louse comb, or prescription options from a healthcare provider.
Home remedies such as petroleum jelly or herbal treatments have not been evaluated for effectiveness on head lice infestations.1
Presenter Notes References:
Frankowski BL, Bocchini JA, Jr, Council on School Health and Committee on Infectious Diseases. Head lice. Pediatrics. 2010;126:
Gordon S. Shared vulnerability: a theory of caring for children with persistent head lice. J School Nursing. 2007;23(5):
Meinking T, Taplin D, Vicaria M. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology. 4th ed. Mosby Elsevier; 2011:

7. What About Cleaning?
Vacuum floor and furniture where the infested person sat or lay6
Fumigants or fogs are not necessary and may be dangerous if inhaled or absorbed through the skin6
Family bed linens and recently used clothes, hats and towels, as well as personal articles such as combs, brushes and hair clips should be washed in very hot water5
Items that can’t be washed should be sealed in a plastic bag for two weeks5
Presenter Information:
Decontaminating the immediate home environment may be useful in reducing head lice transmission by inanimate objects (fomites, discussed earlier in this presentation).
Additional Information:
To help kill and remove head lice and eggs from the home, the following measures can be used to control the infestation:
Machine launder scarves, pillow cases, bedding, clothing, and towels in hot water (50°/122°F) and dry using the hot air cycle. This kills adult lice and nits. All items used by the infested person(s) within the 2 days before treatment should be cleaned.1,2
To eliminate lice from clothing, dry clean or seal the clothing in a plastic bag for 2 weeks. Items that cannot be laundered but have come into contact with the infested person should be sealed in a plastic bag for 2 weeks.2
References:
Elston DM. Treating pediculosis-those nit-picking details. Pediatr.Dermatol.2007;24(4):
CDC. Lice – Head Lice. Prevention & Control. CDC website. sites/lice/head/prevent.html. September 24, 2013.

8. 2016: Frequency of U.S. Lice with Treatment-Resistant Gene7
Between July 2013 and May 2015, lice from 48 states were collected to be tested
(138 geographic collection sites, ranging from rural to metropolitan areas)
These samples were used to determine the extent and magnitude of lice resistance to the pyrethrin or pyrethroid insecticides commonly used in some over-the-counter (OTC) lice treatments
100% of lice in 42 states samples (88%) were found to have the resistant gene
This indicated that lice that have the treatment-resistant gene are widely present in the US
Presenter Information:
As parents, caregivers, and health care providers determine which treatments are the best option for their child, this slide contains relevant, current information about the current landscape of head lice in the United States. Treatment-resistant super lice are emerging in states across the US.
Additional Information:1
Lice were collected from 48 states from July 2013 to May The study included lice from 138 geographic collection sites, ranging from rural to metropolitan areas, and then analyzed the magnitude of a mutation present in the lice’s DNA that is responsible for super lice’s resistance to the pyrethrin or pyrethroid insecticides commonly used in OTC treatments like Rid or Nix.
As indicated by the red dots on the map, 42 of the 48 states sampled (88% of samples from states tested) showed a resistance gene frequency of 100%, meaning that 100% of the lice tested from that area showed resistance to the pyrethrin or pyrethroid insecticides commonly used in OTC treatments.
Only one site had no mutations, and therefore no treatment-resistant super lice (in Minnesota, shown with the green star).
98.3% of all lice analyzed were found to be resistant to these insecticides.
Presenter Notes References:
Gellatly KJ, Krim S, Palenchar DJ, et al. Expansion of the knockdown resistance frequency map for human head lice (Phthiraptera: Pediculidae) in the United States using quantitative sequencing. J Med Entomol. 2016;53(3):
● Lice with resistant gene = 100%
● Lice with resistant gene = 50-99%
● Lice with resistant gene = 0%
● No population analyzed

9. Supporting Families Facing Head Lice
Children and parents managing head lice may feel stigmatized and ostracized8,9
We can all help support families facing head lice by:
Dispelling myths
Maintaining privacy
Keeping kids in school
Encouraging families to talk to their health care provider
If you want to learn more, contact your school nurse for more Lice Lessons resources or visit NASN.org!
Presenter Information:
It is important for health care providers to support families throughout their treatment journeys. There are a number of resources available at NASN.org that can help school nurses and parents work together to overcome the stigmas associated with this condition and make the best treatment decisions with their health care provider.
Additional Information:1
In 2015 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 providers to become more directly involved in the decision-making process when infestations are detected, noting that resistance to older pediculicide products had 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 health care provider (HCP) would be both timely and welcome.
Presenter Notes References:
Devore CD, Schutze GE, AAP Council on School Health and Committee on Infectious Diseases. Clinical report—head lice. Pediatrics. 2015;135(5):e1355-e1365.

10. Downloadable Resources at NASN.org
Head Lice FAQs available in Spanish & English
Facing Head Lice Guide for Families
Printable Poster
Presenter Information:
Through a collaboration with Arbor Pharmaceuticals, the Lice Lessons educational initiative is focused on dispelling common head lice misconceptions, providing information about the value of engaging healthcare professionals, and building awareness of new and emerging treatment options.
The portfolio of tools and resources available are designed to help school nurses, often on the frontlines of the battle against head lice, reduce fear and stigma and help parents navigate treatment choices. Resources available at nasn.org/nasn/programs/educational-initiatives/lice-lessons
Additional Information:
Printable Poster: “Don’t Let Head Lice Keep You Up At Night!” – a printable poster with guidance for parents.
Head Lice FAQs: A 2-page resource with references, available in Spanish and English.
Facing Head Lice Guide For Families: A simple step-by-step guide for parents and caregivers, including information about treating and removing head lice from the home.
Head Lice Overview For School Nurses: An up-to-date fact sheet reflecting the most current research on preventing, controlling, and treating head lice.
Head Lice Overview For Parents: A quick, easy-to-read fact sheet to help dispel myths and prepare parents before they experience an infestation, available in Spanish and English.
Letters to Parents: Letters to send home to parents for head lice education and in the wake of a possible head lice infestation discovered at school, available in Spanish and English.
Head Lice Overview For School Nurses
Head Lice Overview For Parents
Letters to Parents available in Spanish & English

11. National Association of School Nurses (NASN) and Arbor Pharmaceuticals
The Lice Lessons educational initiative is made possible through a collaboration between the
National Association of School Nurses (NASN)
and Arbor Pharmaceuticals

12. References
Centers for Disease Control and Prevention (CDC). Parasites: Lice: Head Lice: Frequently Asked Questions. Accessed August 21, 2017.
Frankowski BL, Bocchini JA, Jr, Council on School Health and Committee on Infectious Diseases, American Academy of Pediatrics. Clinical report – head lice. Pediatrics. 2010;126(2):
Centers for Disease Control and Prevention (CDC). Parasites: Lice: Head Lice: Diagnosis. Accessed August 21, 2017.
Centers for Disease Control and Prevention (CDC). Parasites: Lice: Head lice: Treatment Frequently Asked Questions. Accessed August 21, 2017.
Centers for Disease Control and Prevention (CDC). Parasites: Lice: Head lice: Treatment. Accessed August 21, 2017.
Centers for Disease Control and Prevention (CDC). Parasites: Head Lice: Prevention & Control. Accessed August 21, 2017.
Gellatly KJ, et al. J Med Entomol. 2016;53(3): Reproduced with permission of the Journal of Medical Entomology.
Parison J, Canyon DV. Head lice and the impact of knowledge, attitudes and practices – a social science overview. In: Management and Control of Head Lice Infestations. UNI-MED, Bremen,Germany, 2010:
Gordon SC. Shared vulnerability: a theory of caring for children with persistent head lice. J Sch Nurs. 2007;23(5):
PP-NP-US-0374