Head Lice

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The head louse is a parasitic insect that is found on the scalp, preferring the nape of the neck and the area behind the ears. The insect is 1-2 mm long (about the size of a sesame seed) and varies in color. Lice are usually translucent when hatched, and then develop a reddish-brown color after feeding. They do not have wings and cannot fly or jump, but they can crawl very quickly. They receive nourishment by sucking blood from the scalp. They do not thrive on pets and need human blood to survive. Little information exists on the natural lifespan of the louse. In laboratory conditions, they can live for about a month; however, lice cannot survive for more than 24 hours off of the human host.
The female louse will deposit around three to four eggs, called nits, per day. Nits are very small, gray or yellow-white ovals and are firmly attached to the hair shaft close to the scalp. Eggs hatch in about a week and mature in eight to nine days. Nits must be laid by live lice, but nits alone are not contagious. Itching, the main symptom of lice infestation, is caused by the lice sucking blood. Secondary infections can occur with scratching. Head lice can be acquired by close contact with an infested person, using infested objects such as coats and brushes, by lying on infested carpets or beds, or by resting the head against upholstered furniture used by an infested person. Fallen hairs with nits attached may also contaminate the environment. One person will usually only have 10 to 20 head lice. Head lice are not a sign of poor hygiene and can affect people of any social or economic class.
Diagnosis
The dignity and privacy of students should be preserved when screening for head lice. Diagnosis of head lice infestation (pediculosis) is made by direct inspection of the hair and scalp for the presence of crawling lice and nits. Most commonly, they will be found at the nape of the neck and behind the ears. Good lighting and a hand magnifier may be helpful. When only a few live lice are present, they may be hard to observe, but a diagnosis can be made by finding recently laid nits, which are usually firmly attached within an inch from the scalp. Nit cases, which are translucent and generally found farther out on the hair shaft, indicate empty egg cases (meaning nits have already hatched or been treated). Dandruff, droplets of hair spray and other scalp debris can sometimes be mistaken for nits. None of these substances, however, are typically attached to the hair shaft as firmly as nits. Therefore an experienced examiner is needed to confirm a diagnosis. Examiners should be careful to prevent transmission to themselves or to others being examined. Disposable gloves may be worn, and wooden applicator sticks may be used to separate the hair. However both should be disposed of after each examination.
Treatment
Adequate control of head lice depends on:
     • Education for school personnel and families 
     • Careful inspection of students
     • Exclusion of affected students from school until treated (only if live lice are present)
     • Measures to prevent transmission from one child to another
Effective treatment can be difficult and takes perseverance on the part of the parent/guardian and excellent communication and screening on the part of the school. Families should receive education about head lice, methods of treatment, referral to healthcare provider, information on how to identify head lice among family members, and instructions on how to clean bedding, personal articles, clothing and the home. Keep in mind that the family’s understanding and ability to comply will be affected by factors such as emotional state, literacy level, culture, language/communication skills, previous experience, poor vision of the caregiver and condition of housing. 
Control of head lice infestation is a community problem that requires the involvement of schools, healthcare providers (including pharmacists), families and local public health authorities. When an active case of head lice is found, the student does not need to be sent home early from school. The student can go home at the end of the day, be treated and return to class after appropriate treatment has begun. Nits may persist after treatment, but successful treatment should kill crawling lice. The American Academy of Pediatrics and National Association of School Nurses believe a child should not miss or be excluded from school because of head lice. Then classmates, friends and siblings should be examined as soon as possible. If a substantial number of cases are found, screening the entire school population should be considered. Routine screenings may be done at the beginning of the school year and after extended holidays such as winter and spring breaks. Notification of families prior to screenings provides an opportunity for health education.
Treatment of head lice must include simultaneous attention to the student and surrounding environment. All persons in the household and other close contacts of the student should be examined. Contacts should be treated only if evidence of lice or nits is found.
Manual Lice and Nit Removal is a necessary part of treatment, whether chemical or “natural” remedies are used separately or in combination. Some experts now believe that lice can be eradicated with very careful lice and nit removal and environmental measures, such as the following:
     • Wear disposable gloves.
     • Use a very bright light or sunlight to inspect the hair. The process takes a while, so having the child and the examiner seated is best.
     • If the examiner is farsighted or has poor vision, a magnifying glass may be necessary.
     • Remove tangles from the hair with a comb or brush.
     • Divide the hair into sections, examining each section individually and then fastening it away from the rest of the hair.
     • Take a one-inch section of hair and use a lice comb to comb each hair section carefully. Not all lice combs work equally well; a comb with stainless steel teeth 2-3 inches long and placed very close together works best. (Licemeister® is one brand.)
     • The comb should be dipped into water after each section is combed. A toothbrush or dental floss may be used to clean the comb as well.
     • Continue combing each section of hair until all is thoroughly combed and checked. Comb can be soaked in hot water after use.
     • The parent should then continue to check each day, as long as re-infestation is possible (generally three weeks).

Chemical/Pesticide Shampoos and Cream Rinses can also be used with some cautions:
     • Refer the child and family to their healthcare provider for instructions for treatment. If the student has no healthcare provider, he may be referred to the local health department for treatment. Several medicated shampoo and cream rinse preparations are available without a prescription. All of these products are toxic medications that need to be used with care, and only when necessary. Lice treatment should be performed by an adult, not by the child. Educate families to seek the advice and counsel of the healthcare provider or pharmacist and read all insert materials before using these products. People with chrysanthemum or ragweed allergies may be sensitive to some of these products.
     • Before using the treatment, shampoo the hair vigorously with regular shampoo to soften and loosen the nits in the hair. Follow this by thoroughly combing the hair with a special fine-tooth comb. These activities can weaken and damage the nit capsules and help the medicated shampoo work. Use the shampoo or rinse as directed by healthcare provider or pharmacist, or as outlined on the product information (Nix® Crème Rinse should be put on towel-dried hair).
        – Do not get any medicated shampoo into the eyes—cover the child’s eyes with a towel and instruct child to keep eyes tightly closed. Any product that does get into the eyes should be rinsed immediately with large amounts of tap water.
        – Keep these products out of reach of young children.
        – Use the products over the sink, not in the tub or shower to avoid exposure of the skin to chemicals. All topical pediculicides should be rinsed from the hair over a sink, using cool water, to minimize product absorption due to vasodilation.
        – Medicated shampoos and cream rinses should not be left on the head longer than directed on the product label (usually 10 minutes). The medicated shampoos and rinses are not preventive and should never be used unless live lice or nits are present.
        – Wash hands well after using these products. 
     • Using a vinegar rinse (1:1 solution of water and white vinegar) after shampooing (except with Nix Crème Rinse) may make it easier to remove nits. No known preparation kills all of the nits so some must be manually removed.
     • After using the product as directed and rinsing, nits must be removed by combing the hair with a special fine-tooth comb made for this purpose. This process is easier with a very bright light, and sometimes a magnifying glass is helpful.
     • Have the child put on clean clothing immediately after the treatment.
     • A student should not miss more than one to two days from school because of head lice. On days two to six after initial treatment, wash the hair with regular shampoo and remove any nits that are still present.
     • Re-treatment after nine days may be necessary to eradicate any lice that may have hatched from nits that were not killed or removed. Do not retreat before seven days. Follow the healthcare provider’s recommendations.
     • Some people have had success using oil, such as mineral or olive oil, to cover the hair, wrapping the head with a towel (not a shower cap), and leaving it on overnight. The oil is then washed out with regular shampoo. Manual removal of lice and/or nits is still necessary after this treatment. Vaseline applied to the eyebrows/eyelashes for 24 hours can treat lice in this area.
     • The entire household should be checked and all infected individuals treated. If the first treatment in a family fails, then all members should be treated.
     • In resistant cases, since lice can only live independent of a human host for approximately 24 hours and some objects in the environment cannot be easily cleaned, families may want to consider moving the child from his environment for 24-36 hours (i.e., stay at another relative’s house for one to two days).

Environmental Measures
     • Machine-washing in hot water and/or drying on the hot cycle of the dryer can disinfect many personal articles, such as bed linens, clothing and headgear. Eggs can be killed in 10-15 minutes at 130º F, and live lice at slightly lower temperatures. Allow time between loads of laundry for the water to regain its maximum water temperature. If only the dryer is available, dry articles for at least 20 minutes at the high heat setting.
     • Articles that are not washable may be effectively disinfected in the dryer if the heat will not harm them.
     • Dry cleaning or storing items in a tightly sealed plastic bag for 10-14 days is also effective.
     • Vacuum mattresses, pillows, upholstered furniture, car seats and carpeting. Discard contents of vacuum bag immediately in plastic trash bags.
     • Combs and brushes should be soaked in hot water for one hour.
     • To control the spread of head lice, infested persons should not share items that come into contact with the head, neck or shoulders (e.g., combs, brushes, hats, scarves, coats, towels, stuffed animals child sleeps with).
     • Handwashing and cleaning under fingernails is also important since nits could get under the nails when scratching and easily be spread to others.
     • Animals in the home do not carry lice.
     • Do not use dog shampoo, kerosene or other unapproved products. They do not kill lice and can be dangerous.
     • Treatment should focus on the infested person and his/her personal articles. The U.S. Public Health Service does not recommend fumigation or use of insecticides in the home, school or on school buses.

Cautions from the National Pediculosis Association:
     • Don’t use shower caps during treatment and never leave the product on longer than directed.
     • Don’t use a prescription product containing the pesticide LINDANE.     
     • Don’t use a chemical treatment on or near the eyes.
     • Don’t use a chemical head lice treatment on a baby.
     • Don’t use lice sprays. • Don’t treat individuals who are not infested.
     • Don’t use chemical treatments to prevent head lice

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