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The Strange World of Head Lice Information

By John Smithkey III, RN, BSN

Part One | Part Two

Part Two - My first article in a series of writings resulted from researching the treatment of head lice in both the preschool as well as the regular school settings. What I found was information that was often confusing, and at times made me angry since it appeared it was written for the benefit of the drug companies and not the children. (See previous article.)

There are interesting aspects of the Contemporary Pediatrics Supplement of August 2000 “Guidelines for the Treatment of Resistant Pediculosis” in addition to those I addressed earlier. For example, why do the Guidelines discourage screening, a tried, tested and rational approach to protecting children’s health?

In the Guidelines, the panel of experts stated that “mass screenings are disruptive and not warranted.” What these experts overlooked is the fact that health screening for both preschool and elementary students are held during the school day for many different reasons. Physical education and health teachers and school nurses frequently conduct height and weight screenings throughout the school year: hearing, vision, and dental examinations are also performed during school hours. The students and school personnel (nurses and teachers) are accustomed to taking part in mass screenings.

A classroom or school-wide screening is the most economical and effective way to both find cases of head lice as well as teach parents and students about this age old health problem in a positive way. As stated earlier, screenings are in no way new or disruptive in the school environment. This type of head lice screening requires no expensive equipment; the examination is totally non-invasive as well as painless. What is required is planning and preparation on the part of school administrators, the school nurse, teaching staff and families. Screening must be scheduled in advance, parents notified and adapted to accommodate the varied resources available in different schools. Although the preferred approach would be to utilize only medical professionals, reality dictates that, since many districts don’t even have a school nurse assigned to each school, other resources must be utilized for this process. Sensitivity to the child’s feelings, the issue of confidentiality and accurate diagnosis must be at the forefront of any screening program.

According to the Guidelines, Hansen and colleagues stated, “Positive diagnosis is essential to avoid indiscriminate use of therapies, which can lead to resistance.” Is Hansen once again suggesting that lice can develop resistance if you treat a child who doesn’t have them? Regardless, Hansen is indeed partly correct. No healthcare provider wants to subject a patient to indiscriminate use of therapy or unwarranted treatment.

As screening programs must be adapted to the school and resources, No Nit Policies (although discounted in the Guidelines) form the basis for responsible head lice management. The National Pediculosis Association claims that its No Nit Policy sets the standard for promoting screening, early detection and manual removal – keeping children in school lice and nit free and ready to learn. The policy states: “Early detection offers the best opportunity to manually remove head lice and nits without pesticide exposure and unnecessary absenteeism. This directive is consistent with traditional preventive medical and communicable disease control methods.”

Each year brings new health issues, risks and challenges to the School Nurse. My experience has been that any opportunity to be proactive (such as with a screening program) benefits everyone concerned – especially the kids – as opposed to the alternative which is to try to manage head lice with crisis intervention.

John Smithkey III, RN, BSN
Certified School Nurse, State of Ohio
June 2003

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Part One - As I moved along in my studies and research in my chosen field of a school nurse, I became increasingly interested in the area of treatment of head lice among school and preschool children.  I realized that most childhood illnesses had a set course of prescribed treatments one would assume was based on scientific and medical evidence.  I discovered this was not necessarily the case with head lice and came upon an example that blew me away.  No doubt some treatment recommendations are based on science, but check this out.

They call it the "Guidelines for Resistant Lice" from an expert panel that met at the Harvard School of Public Health and was funded by the makers of the malathion product known as Ovide.  The consensus of their meeting was published as a supplement in Contemporary Pediatrics.  I could find no sign of independent peer review.  These are the same Guidelines that supposedly reversed all that was known about managing head lice and are commonly referred to by others setting new policy on head lice including the American Academy of Pediatrics.

The expert panel was mainly individuals who worked for the makers of lice treatment products.  Even overlooking their apparent bias, the kicker was their list of factors that cause head lice to become resistant to drug therapy.  The authors listed and highlighted them in the publication.  Their list of factors is not only inaccurate, it is bizarre.

Factors contributing to lice resistance:
  • Inappropriate use of pediculicides in non-lice cases (dandruff, pseudonits).
    • How can a louse become resistant when there are no lice in the patient's hair?  If there are no lice, resistance cannot occur!
       
  • Overuse of over-the-counter treatments on nonviable nits or dead lice.
    • Resistance cannot develop when a product is applied to dead organisms, whether it is overused or not.
       
  • Misuse of pediculicides (not following product instructions).
     
  • Use as prophlaxis.
    • How do you create resistance when you use a treatment as a preventive before you even have lice or nits?

I am baffled.  Did anybody proof this document?  Better yet, did anybody read it?  How did the professional organization that represents school nurses approve this report?

Needless to say, I was stunned as I read this set of Guidelines.  Because of the confusion they have created, I have decided to present a series of articles on HeadLice.Org that I hope will cast some light on a very confusing problem!

John Smithkey III, RN, BSN
Certified School Nurse, State of Ohio
May 2003

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