There is little that is new in the August 29th, 2002
release issued by the American Academy of Pediatrics as guidelines for
clinicians dealing with head lice.
The guidelines do little to eliminate the confusion and
misinformation that has always been the hallmark of pediculosis management. In
the absence of a nationally standardized approach, head lice remain a
controversial issue with differences between industry driven guidelines for
treatment and consumer needs and wants for safer and more effective choices.
While school absence is a problem, readmitting an infested child is no solution.
The National Pediculosis Association® (NPA) works to minimize the politics of lice by focusing
on what is most helpful in a practical sense to parents and least disruptive to
family and school life. Just like brushing one’s teeth, the NPA recommends
routine screening as a step in basic hygiene, with early detection of lice and
nits and thorough manual removal. This allows parents to avoid panic, more
challenging long-term infestations, and the use of a variety of potentially
toxic chemical treatments such as those that contain lindane and malathion. The
NPA’s goal is to protect children from the misuse and abuse of pesticidal
treatments and to keep children in school lice and nit free and ready to learn.
The AAP guidelines are consistent with the organization’s
longstanding opposition to a No Nit Policy. AAP advocates keeping children in
school with lice and nits. The NPA has a recommended No Nit Policy establishing
a public health standard that puts education and prevention in advance of
outbreaks. And while this may be the common goal for all No Nit Policies, it
should be clarified that all Policies are not the same. Schools and nursing
personnel must tailor their management policies to their resources and
particular situations. Just this week, we were contacted for help by a school
nurse in Utah who was one of only 3 school nurses responsible for children in 36
schools. These school nurses, along with thousands of others like them, rely
heavily on the participation and cooperation of parents.
The AAP guidelines surprisingly give little if any credit
to the school nurses and their ability to accurately screen for head lice and
limit infestations. This is unfortunate, since thanks to school and public
health nurses, thousands of communities are doing an excellent job controlling
head lice without the use of pesticidal products. This can be documented by the
continuing decline of pediculicide product sales.
Some of the key information in the AAP clinical report is
regrettably out of date. For example, the AAP states that lindane “ should be
used very cautiously,” however new labeling will prohibit its use for children.
Malathion has no safety studies available on children under the age of 6, yet
the report states; “it can be used with extreme caution in the treatment of only
those cases in which resistance to other products is strongly suspected.” The
most obvious concern about this directive is that pesticides accumulate in the
body; lice products are not intended nor approved by the FDA to be used
repeatedly, in conjunction with, or as a follow-up to other chemical
formulations. Thankfully, the AAP report does advise against the use of lice
sprays for bedding and the environment, which is a commonly ignored additional
and unnecessary chemical exposure.
AAP is far too casual about resistance issues as this is a
major factor in overuse and over-exposure to pesticidal treatments. Resistance
and cross resistance to the most popular remedies including permethrin is well
established, as reported at the Congress on Lice held this July in Australia and
reiterated at the American Chemical Society’s annual meeting in Boston last
week. However the AAP states; “the prevalence of this (permethrin) resistance is
Nor does the AAP address the growing number of children
and families for whom a non-chemical approach to controlling head lice is
critical. Treatment decisions must be based on the unique vulnerabilities of
each person. Pesticide treatments or chemical agents of any kind are
contraindicated for a variety of individuals including but not limited to
infants, young children, and the growing number of those with chronic illness,
having chemotherapy, using medications, or simply already overexposed to
pediculicides. Treating for head lice puts both the person applying the
treatment, as well as the person receiving treatment at risk. This is especially
important for pregnant or nursing mothers.
School nurses, public health nurses and school principals
who have found success with their No Nit Policies will continue to enforce them
regardless of AAP guidelines …just as the NPA will continue to encourage
communities to be proactive about screening, early detection, and manual removal
to prevent the use of pesticides on children. As our motto states, “Because it’s
not about lice, it’s about kids.”