05/01/03 - John Smithkey of Canton,Ohio finds "Guidelines for Resistant Lice" suspect. The National Pediculosis Association urges other school nurses and pediatricians to follow his lead and review more closely the document published and accepted as public health policy by many health professionals without due diligence.

John Smithkey III, RN, BSN, of Canton, Ohio set out to research why his school policy excluded children with head lice and nits.

He was angry as he thought their position flew in the face of the current guidelines supported by the National Association of School Nurses (NASN) and the American Academy of Pediatrics (AAP).

In doing his research, he found that NASN and AAP recommendations were based on the August 2000 "Guidelines for Resistant Lice" which were developed by an expert panel that met at the Harvard School of Public Health, (guidelines here).

This panel was funded by the makers of Ovide, a Malathion prescription product for head lice. The panel's recommendations were printed as a supplement in the publication Contemporary Pediatrics.

Smithkey also found that the expert panel was made up mainly of individuals who directly or indirectly worked for the makers of lice treatment products. Not surprisingly, the panel's recommendations included over-the-counter treatments and the prescription Malathion.

Smithkey points out apparent conflicts of interest but describes the “kicker” as their list of factors that cause head lice to become resistant to drug therapy.

The Guidelines list the following four factors as contributing to lice resistance:

1. Inappropriate use of pediculicides in non-lice cases (dandruff, pseudonits).

Smithkey asks how a louse becomes resistant when there are no head lice in the patient’s hair. If there are no lice, resistance cannot occur!

2. Overuse of over-the-counter treatments on nonviable nits or dead lice.

Resistance cannot develop when pesticides are applied to dead organisms.

3. Misuse of pediculicides (not following product instructions).

4. Use as prophylaxis.

How do you create resistance when you use a treatment as a preventive before you even have lice or nits?

Smithkey says "I could find no sign of independent peer review," and uses their resistance factors as a reason to question the validity of the Guidelines. He wonders "Did anybody proof this document?" and asks if anybody even read it before adopting it as public health policy. Finally he asks: "How did the professional organization that represents school nurses approve this report?"

When the Guidelines were first published in 2000, the NPA submitted a report to the Dean of the Harvard School of Public Health on the inaccuracies, misleading information and inappropriate product recommendations contained in the Guidelines that put children's health at risk. The Dean took no action.

The National Pediculosis Association (NPA) urges other school nurses, school administrators and pediatricians to follow Smithkey’s lead and review more closely the document that is currently being utilized in many communities throughout the country for public health policy.

Smithkey's editorial can be found here.