CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Head Lice Cynthia D. Devore, MD, FAAP, Gordon E. Schutze, MD, FAAP, THE COUNCIL ON SCHOOL HEALTH AND COMMITTEE ON INFECTIOUS DISEASES

Head lice is associated with limited morbidity but causes a high abstract level of anxiety among parents of school-aged children. Since the 2010 clinical report on head lice was published by the American Academy of Pediatrics, newer have been approved for the treatment of head lice. This revised clinical report clarifies current diagnosis and treatment protocols and provides guidance for the management of children with head lice in the school setting.

Head lice ( humanus capitis) have been companions of the species since antiquity. Anecdotal reports from the 1990s estimated annual direct and indirect costs totaling $367 million, including remedies and other consumer costs, lost wages, and school system expenses. More recently, treatment costs have been estimated at $1 billion.1 It is important to note that head lice are not a health hazard or a sign of poor hygiene and This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed are not responsible for the spread of any disease. Despite this knowledge, conflict of interest statements with the American Academy of there is significant stigma resulting from head lice in many Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of developed countries, resulting in children being ostracized from their Pediatrics has neither solicited nor accepted any commercial schools, friends, and other social events.2,3 involvement in the development of the content of this publication. In the past, parents and other non–health care personnel made the Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external diagnosis of head lice, and the easy availability of safe and effective over- reviewers. However, clinical reports from the American Academy of the-counter (OTC) pediculicides often removed the physician from the Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent. treatment process. However, the potential for misdiagnosis and the resulting improper use of pediculicides and the emergence of resistance to The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking both available and newer products, many without proof of efficacy or into account individual circumstances, may be appropriate. safety, call for increased physician involvement in the diagnosis and All clinical reports from the American Academy of Pediatrics treatment.4,5 Optimal treatments should be safe, should rapidly rid the automatically expire 5 years after publication unless reaffirmed, individual of live lice, viable eggs, and residual nits, and should be easy to revised, or retired at or before that time. use and affordable.6 Additionally, because lice infestation is benign, FINANCIAL DISCLOSURE: The authors have indicated they do not have a financial relationship relevant to this article to disclose. treatments should not be associated with adverse effects and should be reserved for patients on whom living lice are found. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest relevant to this article to disclose.

ETIOLOGIC AGENT www.pediatrics.org/cgi/doi/10.1542/peds.2015-0746 DOI: 10.1542/peds.2015-0746 The adult head is 2 to 3 mm long (the size of a sesame seed), has 6 legs, and is usually tan to grayish-white in color. The female lives up to 3 to PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). 4 weeks and, once mature, can lay up to 10 eggs per day. These tiny eggs Copyright © 2015 by the American Academy of Pediatrics

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 135, number 5, May 2015 FROM THE AMERICAN ACADEMY OF PEDIATRICS are firmly attached to the base of influenced by hair length or by nurses, teachers, and parents to the hair shaft within approximately frequent brushing or shampooing. a laboratory for identification were 4 mm of the scalp with a gluelike found to be artifacts, such as substance produced by the louse. Viable TRANSMISSION dandruff, hairspray droplets, scabs, eggs camouflaged with pigment to dirt, or other (eg, aphids match the hair color of the infested Lice do not hop or jump; they can blown by the wind and caught in the person often are seen more easily at the only crawl, and pets do not play hair).5 In general, eggs found more posterior hairline. Empty egg casings a role in the transmission of human than 1 cm from the scalp are unlikely 9 (nits) are easier to see because they lice. However, there are reports that to be viable, although some appear white against darker hair. combing dry hair can build up researchers in warmer climates have (Note that some experts refer to enough static electricity to physically found viable eggs farther from the “eggs” as containing the developing eject an adult louse from an infested scalp.8 10 nymph and use “nits” to refer to scalpforadistanceof1m. In most empty egg casings; others use the cases, transmission occurs by 9,11 term “nits” to refer to both eggs and direct contact. Indirect spread PREVENTION through contact with personal the empty casings). The eggs are It is unlikely that all head lice belongings of an infested individual incubated by body heat and typically infestations can be prevented, (combs, brushes, hats) is much less hatch in 8 to 9 days, but hatching because young children come into likely to occur.12 Lice found on combs can vary from 7 to 12 days depending head-to-head contact with each other are likely to be injured or dead,13 on whether the ambient climate is hot frequently. It is prudent for children and a louse is not likely to leave or cold. Once it hatches, a nymph to be taught not to share personal a healthy head unless there is a heavy leaves the shell casing and passes items, such as combs, brushes, and infestation.14 In 1 study, live lice were through a total of 3 nymph stages hats, but one should not refuse to found on only 4% of pillowcases (instars) during the next 9 to 12 days wear protective headgear because of used by infested volunteers.15 Thus, before reaching the adult stage. The fear of head lice. In environments the major focus of control activities female louse can mate and begin to where children are together, infested should be to reduce the number of lay viable eggs approximately children should be treated promptly lice on the head and to lessen the 1.5 days after becoming an adult. If to minimize spread to others. Regular risks of head-to-head contact. not treated, the cycle repeats itself surveillance by parents is one way to approximately every 3 weeks.7 detect and treat early infestations, The louse feeds by injecting small DIAGNOSIS thereby preventing the spread to amounts of saliva, which has Identification of eggs (nits), nymphs, others. vasodilatory and anticoagulation or adult lice with the naked eye properties, into the scalp, allowing establishes the diagnosis. This can be TREATMENT the louse to suck tiny amounts of difficult sometimes because lice blood every few hours. Pruritus avoid light and can crawl quickly. Never initiate treatment unless there results from sensitization to Studies have revealed that diagnosis is a clear diagnosis with living lice. components of the saliva. With a first of infestation by using a louse comb The ideal treatment of lice should be case of head lice, pruritus may not is quicker and more efficient.16 safe, free of toxic chemicals, readily develop for 4 to 6 weeks, because it Some experts have suggested using available without a prescription, easy takes that amount of time for a lubricant (water, oil, or to use, effective, and inexpensive. sensitivity to result. conditioner) to “slow down” the Local patterns of resistance (if known), ease of use, and cost Head lice usually survive for less than movement of lice and eliminate the 17 (Table 1) also are considerations 1 day away from the scalp, and their possibility of static electricity. Tiny when choosing a treatment choice. eggs cannot hatch at temperatures eggs may be easier to spot at the Published reviews of available lower than those near the scalp.8 nape of the neck or behind the ears, within 1 cm of the scalp. It is efficacy studies and comparative important not to confuse eggs or trials of pediculicides have used EPIDEMIOLOGY nits, which are firmly affixed to the different inclusion criteria and In the United States, reliable data on hair shaft, with dandruff, hair casts, reached different conclusions.18–20 A prevalence of head lice are not or other hair debris, which are not. It Cochrane review concerning available.9 All socioeconomic groups is also important not to confuse live pediculicides has a substantial update are affected, and infestations are seen eggs with dead or empty egg cases under way, because previous reviews throughout the world. Head lice (nits). Many presumed “lice” and were conducted before the infestation is not significantly “nits” submitted by physicians, development of drug resistances.21

Downloaded from www.aappublications.org/news by guest on September 26, 2021 e1356 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 1 Topical Pediculicides for the Treatment of Head Lice in the United States after rinsing. In addition, none of Product Availability Cost Estimate these natural pyrethrins are totally 1% lotion (Nix) OTC $ ovicidal (newly laid eggs do not have Pyrethrins + piperonyl butoxide (Rid) OTC $ a nervous system for several days); 0.5% (Ovide) Prescription $$$$ 20% to 30% of eggs remain viable Benzyl alcohol 5% (Ulesfia)a Prescription $$-$$$$ after treatment,24 which necessitates Spinosad 0.9% suspension (Natroba) Prescription $$$$ a second treatment to kill newly 0.5% lotion (Sklice) Prescription $$$$ emerged nymphs hatched from eggs Adapted from refs 18, 40. fi $, ,$25; $$, $26–$99; $$$, $100–$199; $$$$, $200–$299. that survived the rst treatment. a Cost varies based on the length of the hair and the number of bottles of required. Suggested retreatment with these products is similar to permethrin The guidance in this report is eggs not killed with the first (1%) described previously.26 intended for use by pediatricians and application.24 However, conditioners Although pyrethrins were extremely other practitioners in the United and silicone-based additives present effective when introduced in the mid- States. The Canadian Pediatric Society in almost all currently available 1980s, recent study results have recently updated its position shampoos impair permethrin indicated that efficacy has decreased statement on head lice infestation.22 adherence to the hair shaft and substantially because of development Pediatricians who work in other reduce its residual effect.6 Although of resistance.4 The prevalence of countries, especially developing many repeat the application resistance has not been countries in which head lice are naive sometime between day 7 to 10 after systematically studied but seems to to pediculicides, should use treatment if live lice are seen, new be highly variable from community to products or methods that are most evidence based on the life cycle of lice community and country to country. economical, effective, and safe. The suggests that retreatment at day 9 is following products and methods can optimal.6,25 An alternate treatment Malathion (0.5%) be effective for treating head lice. schedule on days 0, 7, and 13 to 15 The organophosphate (cholinesterase has been proposed on the basis of the Pediculicides inhibitor) 0.5% malathion (Ovide; longest possible life cycle of lice for Taro Pharmaceutical Industries, Permethrin (1%) this and other nonovicidal agents Hawthorne, NY) was reintroduced for Permethrin has been the most (eg, pyrethrins plus piperonyl the treatment of head lice in the studied pediculicide in the United butoxide).26 Resistance to 1% United States in 1999 after being – States and is the least toxic to permethrin has been reported,6,27 30 taken off the market twice because of .18 Introduced in 1986 as but its prevalence is unknown. problems related to prolonged a prescription-only treatment, 1% application time, flammability, and permethrin lotion was approved for Pyrethrins Plus Piperonyl Butoxide odor. It is available only by OTC use in 1990 and is marketed as Manufactured from natural extracts prescription as a lotion that is applied a “creme rinse” (Nix; Insight from the chrysanthemum, pyrethrins to dry hair, left to air dry, then washed Pharmaceuticals, Trevose, PA). One are formulated with piperonyl off after 8 to 12 hours, although percent permethrin lotion is one of butoxide (eg, RID; Bayer HealthCare some study results have suggested the drugs available to treat head LLC, Whippany, NJ) and are available effectiveness when left on for as short lice.23 Permethrin is a synthetic OTC. Pyrethrins are neurotoxic to lice a time as 20 minutes.32 Head lice in with extremely low but have extremely low mammalian the United Kingdom and elsewhere mammalian toxicity. Reported toxicity. Pyrethrins should be avoided have shown resistance to malathion adverse effects include pruritus, in people who are allergic to preparations, which have been erythema, and edema. Permethrin is chrysanthemums. The labels warn available for decades in those less allergenic than pyrethrins and against possible allergic reaction in countries.33,34 The current US does not cause allergic reactions in patients who are sensitive to formulation of malathion (Ovide individuals with plant allergies. The ragweed, but modern extraction lotion, 0.5%) differs from the product is applied to damp hair that techniques minimize the chance of malathion products available in is first shampooed with product contamination, and reports in that it contains terpineol, a nonconditioning shampoo and then of true allergic reactions have been dipentene, and pine needle oil, which towel dried. It is left on for 10 rare.31 These products are available themselves have pediculicidal minutes and then rinsed off. in shampoo or mousse formulations properties and may delay Permethrin leaves a residue on the that are applied to dry hair and left on development of resistance. Malathion hair that is designed to kill nymphs for 10 minutes before rinsing out. has high ovicidal activity,24 and emerging from the 20% to 30% of No residual pediculicidal activity remains a single application is adequate for

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 135, number 5, May 2015 e1357 most patients. When compared with should be applied topically for a lotion form by the FDA in 2012 for pyrethrins and permethrin, malathion 10 minutes and repeated as stated children 6 months or older for head was the most pediculicidal and previously for permethrin 1%. Benzyl lice. This medication increases the ovicidal agent with highest cure rates alcohol is available by prescription chloride ion permeability of muscle after 1 application.6,32 However, the and should not be used in neonates, cells, resulting in hyperpolarization, product should be reapplied in 7 to because it has been associated with paralysis, and death of the lice.41 9daysiflivelicearestillseen.Thehigh the neonatal gasping syndrome.36 Combined data from 2 multisite, alcohol content of the product (78% randomized, double-blinded studies isopropyl alcohol) makes it highly Spinosad (0.9% Suspension) comparing a single application of flammable; therefore, patients and Spinosad (Natroba; ParaPRO LLC, 0.5% ivermectin lotion with a vehicle their parents should be instructed to Carmel, IN) was approved by the FDA control found that significantly more allow the hair to dry naturally; not to for topical use in children 6 months patients receiving ivermectin were use a hair dryer, curling iron, or flat of age and older. It is contraindicated louse free on day 2 as compared with iron while the hair is wet; and not to for children younger than 6 months the control (94.9% vs 31.1%), day 8 smoke near a child receiving because it also contains benzyl (85.2% vs 20.8%), and day 15 treatment. Safety and effectiveness of alcohol. The compounds, spinosyn A (73.8% vs 17.6%; P , .001 for each malathion lotion have not been and spinosyn D, are derived through comparison).41 Topical ivermectin established in children younger than natural fermentation from soil lotion is available by prescription, is 6 years, and the product is bacterium, Saccharopolyspora applied to dry hair and scalp, and is contraindicated in children younger spinosa. They are suspended in rinsed after 10 minutes. Only 1 than 24 months. Because malathion is a natural ratio of 5:1 and together are application is required, because a cholinesterase inhibitor, there is known by the generic term spinosad. when the treated eggs hatch, the lice a theoretical risk of respiratory Spinosad has a broad spectrum of are not able to feed as a result of depression if accidentally ingested, activity against insects, including pharyngeal muscle paralysis and, although no such cases have been many species of lice. Activity appears therefore, are not viable.42 Adverse reported. to be both ovicidal and pediculicidal effects are rare and include skin or by disrupting neuronal activity and eye irritation and erythema, burning, Benzyl Alcohol 5% lingering long enough to exert its or dryness.41 fi effect on the developing larvae until Benzyl alcohol 5% (Ules a; Concordia Lindane (1%) Pharmaceuticals, Inc, Bridgetown, they form an intact nervous Barbados) was approved by the US system.37 Superiority of spinosad Lindane is no longer recommended Food and Drug Administration (FDA) over permethrin has been by the American Academy of Medical Letter in April 2009 for treatment of head demonstrated with treatment success Pediatrics or the for lice in children older than 6 months. rates of 84% to 87% as compared use as treatment of The product is not neurotoxic to the with 43% to 45%.38 Adverse capitis. lice, but kills them by asphyxiation. reactions described include Removal of Topical Pediculicides Phase III trials of this agent have application site erythema (3%), included 2 randomized, multicenter, ocular erythema (2%), and All topical pediculicides should be – double-blind, vehicle-controlled trials application site irritation (1%).38 40 rinsed from the hair over a sink and 1 open-label study.35 The overall Spinosad is available by prescription rather than in the shower or bath to end point of these trials was and should be applied to dry hair by limit skin exposure, and with warm treatment success or no live lice at saturating the scalp and working rather than hot water to minimize 14 days after the final application. outward to the ends of the hair, absorption attributable to The effectiveness of benzyl alcohol which may require a whole bottle. vasodilation.43 (75.0%–76.2%) was statistically Spinosad should be rinsed greater as compared with vehicle 10 minutes after application. A second Topical Reactions placebo (4.8%–26.2%). The most treatment is given at 7 days if live lice Itching or mild burning of the scalp common adverse reactions after are seen. Safety in children younger caused by inflammation of the skin in treatment included pruritus (12%), than 4 years has not been response to topical pharmaceutical erythema (10%), pyoderma (7%), established. agents can persist for many days after and ocular irritation (6%).17 When lice are killed and is not a reason for applied, sufficient amounts should be Ivermectin (0.5%) retreatment. Topical corticosteroids used on dry hair to saturate the scalp Ivermectin (Sklice; Sanofi Pasteur, and oral antihistamines may be and entire length of the hair. Benzyl Swiftwater, PA), a widely used beneficial for relieving these signs alcohol is not ovicidal and, therefore, anthelmintic agent, was approved in and symptoms.

Downloaded from www.aappublications.org/news by guest on September 26, 2021 e1358 FROM THE AMERICAN ACADEMY OF PEDIATRICS Scabicides Used Off-Label for Lice Sulfamethoxazole-Trimethoprim insecticidal chemicals produce toxic fi Permethrin (5%) The oral antibiotic agent effects as well. The safety and ef cacy of herbal products are currently not Permethrin 5% is not currently sulfamethoxazole-trimethoprim regulated by the FDA, and until more approved by the FDA for use as (Septra [Monarch Pharmaceuticals, Bristol, TN], Bactrim [Mutual data are available, their use in infants a pediculicide. Five percent and children should be avoided. permethrin (Elimite; Prestium Pharmaceutical, Philadelphia, PA], and generic cotrimoxazole) has been Pharma, Inc, Newton, PA) is available Occlusive Agents by prescription only as a cream, cited as effective against head lice. It “ usually applied overnight for is not currently approved by the FDA Occlusive agents, such as petrolatum ” for infants as young as 2 months. It for use as a pediculicide.52 It is shampoo, mayonnaise, butter or has been used for the treatment of postulated that this antibiotic agent margarine, herbal oils, and olive oil, head lice that seem to be recalcitrant kills the symbiotic bacteria in the gut applied to suffocate the lice are to other treatments.44 The results of 1 of the louse or perhaps has a direct widely used but have not been study suggested that lice resistant to toxic effect on the louse. The results evaluated for effectiveness in 1% permethrin will not succumb to of 1 study indicated increased randomized controlled trials. To date, higher concentrations.29 effectiveness when sulfamethoxazole- only anecdotal information is trimethoprim was given in available concerning effectiveness. Crotamiton (10%) combination with permethrin 1% An uncontrolled, nonrandomized when compared with permethrin 1% Crotamiton is not currently approved by 2004 study reported a 96% “cure” or sulfamethoxazole-trimethoprim the FDA for use as a pediculicide. This rate with Cetaphil cleanser (Galderma alone; however, the treatment groups product is available by prescription only Laboratories, Fort Worth, TX) applied were small.53 Rare severe allergic as a lotion (Eurax; Ranbaxy, Jacksonville, to the hair, dried on with a reactions (Stevens-Johnson FL), usually used to treat scabies. One handheld hair dryer, left on overnight, syndrome) to this medication make it study showed it to be effective against and washed out the next morning and a potentially undesirable therapy if head lice when applied to the scalp and repeated once per week for 3 weeks. alternative treatments exist.7 left on for 24 hours before rinsing out.45 Instructions for its use are available Other reports have suggested that 2 on the Internet.57 It has not been ALTERNATIVE APPROACHES consecutive nighttime applications approved by the FDA for use as safely eradicate lice from adults.46 Safety “Natural” Products a pediculicide. Dimethicone lotion and absorption in children, adults, and (4% long-chain linear silicone in Essential oils have been widely used pregnant women have not been a volatile silicone base) in two 8-hour in traditional medicine for the evaluated. treatments 1 week apart eradicated eradication of head lice, but because head lice in 69% of participants in the Oral Agents Used Off-Label for Lice of the variability of their constitution, United Kingdom.58 In the United the effects may not be reproducible.54 Ivermectin States, the OTC product LiceMD In addition, these oils (eg, ylang ylang (Reckitt-Benckiser, Slough, England) This product (Stromectol; Merck & oil) may be a source of contact contains dimethicone, an emollient. Co, Whitehouse Station, NJ) is an sensitization, which limits their use. Isopropyl myristate 50% (Resultz; anthelmintic agent structurally Several products have been studied Nycomed Canada, Inc, Oakville, similar to macrolide antibiotic agents, (eg, Andiroba oil, Quassia vinegar, Ontario, Canada), a hair rinse that but without antibacterial activity. A melaleuca oil [tea tree oil], lavender dissolves the waxy exoskeleton of the single oral dose of 200 mg/kg, oil).55,56 As natural products, they louse, which leads to dehydration and repeated in 10 days, has been shown are not required to meet FDA efficacy death of the louse, has recently to be effective against head lice.47,48 and safety standards for become available in Canada.59,60 Most recently, a single oral dose of pharmaceuticals. HairClean 1-2-3 Close surveillance of patients treated 400 mg/kg, repeated in 7 days, has (Quantum Health, Eugene, OR [anise, with non–FDA-approved products been shown to be more effective than ylang-ylang, coconut oils, and may improve discovery of treatment 0.5% malathion lotion.49 Ivermectin isopropyl alcohol]) was found to be at failure early, so other evidence-based may cross the blood/brain barrier least as effective as the permethrin and FDA treatments might be and block essential neural product Nix by 1 investigator.2 implemented. transmission; young children may be Although many plants naturally at higher risk of this adverse drug produce insecticides for their own reaction. Therefore, oral ivermectin protection that may be synthesized Desiccation should not be used for children who for use by humans, such as The AirAllé (Larada Sciences, Salt weigh less than 15 kg.50,51 , some of these Lake City, UT) device is a custom-built

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 135, number 5, May 2015 e1359 machine that uses one 30-minute process easier.63–66 Nit-removal New Products application of hot air in an attempt to combs are sold commercially. As new products are introduced, it is desiccate the lice. One study showed However, it appears that type of important to consider effectiveness, that subjects had nearly 100% comb used is less important than safety, expense, availability, patient mortality of eggs and 80% mortality that combing occurs after treatment, preference, and ease of application. 61 of hatched lice. The machine is which may be most easily Assessment of the severity of the expensive, and the operator requires accomplished on wet hair. Studies infestation, the number of special training in its use. A regular have suggested that lice removed by recurrences, the local levels of blow dryer should not be used in an combing and brushing are damaged resistance to available pediculicides, 11 attempt to accomplish this result, and rarely survive. exclusion of children from school, and because investigators have shown There are battery-powered the potential for transmission also are that wind and blow dryers can cause “electronic” louse combs with important when deciding about the live lice to become airborne and, thus, oscillating teeth (MagiComb; use of newer products. potentially spread to others in the Quantum Health, Eugene, OR) that vicinity. claim to remove live lice and nits as Pediculicide Resistance Other Agents well as combs that resemble small No currently available pediculicide is “bug zappers” (Robi-Comb; LiceGuard 100% ovicidal, and resistance to fl Highly ammable substances, such as LLC, Needham, MA) that claim to kill pyrethrins, permethrin, and the gasoline or kerosene, or products live lice.67 No randomized, case- United Kingdom formulation of intended for use, are never controlled studies have been malathion has been appropriate in treatment of head lice performed with either type of comb. reported.33,34,70–75 This resistance is in humans. Their instructions warn not to use on not unanticipated, because insects people with a seizure disorder or develop resistance to products over Manual Removal a pacemaker. time. The actual prevalence of Although there is little peer- resistance to particular products is Some products are available that reviewed information in the not known and can be regional. It is claim to loosen the “glue” that literature about the benefits of the important that health care attaches nits to the hair shaft, thus manual removal of live lice and nits, professionals choose safe and making the process of “nit-picking” the inherent safety of the manual effective products. When faced with easier. Vinegar or vinegar-based removal relative to the minor toxicity a persistent case of head lice after products are intended to be applied of the pesticides is real and can be using a pharmaceutical pediculicide, to the hair for 3 minutes before part of an arsenal by pediatricians health care professionals can consider combing out the nits. No clinical when determining treatment several possible explanations, benefit has been demonstrated.7,68 options. There is an obvious benefit including the following: This product has not been tested of the manual removal process that with and is not indicated for use • misdiagnosis (no active infestation can allow a parent and child to have with permethrin, because it may or misidentification); some close, extended time together interfere with permethrin’sresidual • while safely removing infestations lack of adherence (patient unable activity. A variety of other products, and residual debris without using or unwilling to follow treatment from acetone and bleach to vodka potentially toxic chemicals on the protocol); and WD-40 (WD-40 Company, San child or in the environment. • inadequate treatment (not using Diego, CA), have proved to be Furthermore, manual removal of nits sufficient product to saturate hair; ineffective in loosening nits from will help to diminish the social failing to follow directions); the hair shaft68 and present an stigma and isolation a child can have • reinfestation (lice reacquired after unacceptable risk to the patient. It in the school setting. Individuals also treatment); seems that nature has protected the may want to remove nits for louse by making the nit sheath similar • lack of ovicidal or residual killing aesthetic reasons or to decrease in composition to the hair, so that properties of the product (eggs not diagnostic confusion. Because none agents designed to unravel the nit killed can hatch and cause self- of the pediculicides are 100% sheath can also damage human hair.69 reinfestation); and/or ovicidal, nits (especially the ones • within 1 cm of the scalp) should be Although effective for removing lice resistance of lice to the removed manually after treatment and eggs, shaving the head generally pediculicide. with any product. Nit removal can be is not required, nor recommended, If resistance is proven, and an active difficult and tedious.62 Fine-toothed because it can be traumatizing to infestation is documented, benzyl “nit combs” are available to make the a child and distressing to the parent. alcohol 5% can be prescribed if the

Downloaded from www.aappublications.org/news by guest on September 26, 2021 e1360 FROM THE AMERICAN ACADEMY OF PEDIATRICS patient is older than 6 months, or head lice after 30 minutes of diagnosing and managing head lice malathion 0.5% can be prescribed if swimming.76 Pediculicide spray is not may be helpful.80–83 Parents can be the patient is older than 24 months if necessary and should not be used. encouraged to check their children’s safe use by responsible parents Viable nits are unlikely to incubate heads for lice regularly and if the seems reasonable. For younger and hatch at room temperatures; if child is symptomatic. School patients, or if the parent cannot afford they did, the nymphs would need to screenings do not take the place of or does not wish to use a pediculicide, find a source of blood for feeding these more careful parental manual removal via wet combing or within hours of hatching. Although it checks.13,84–86 It may be helpful for an occlusive method can be used, is rarely necessary, items that cannot the school nurse or other trained with emphasis on careful technique be washed can be bagged in plastic person to check a specific student’s and the use of 2 to 4 properly timed for 2 weeks, a time when any nits that head if he or she is demonstrating treatment cycles. may have survived would have symptoms. hatched and nymphs would die ENVIRONMENTAL INTERVENTIONS without a source for feeding. Management on the Day of Diagnosis If a person is identified with head lice, Exhaustive cleaning measures are not Because a child with an active head fi all household members should be bene cial. lice infestation likely has had the checked for head lice, and those with infestation for 1 month or more by live lice or nits within 1 cm of the CONTROL MEASURES IN SCHOOLS the time it is discovered and poses scalp should be treated. In addition, it Screening little risk to others from the is prudent to treat family members infestation, he or she should remain who share a bed with the person with Screening for nits alone is not an in class, but be discouraged from infestation, even if no live lice are accurate way of predicting which close direct head contact with others. found. Fomite transmission is less children are or will become infested, If head lice is diagnosed in a child, likely than transmission by head-to- and screening for live lice has not confidentiality is important. The fi head contact7; however, it is prudent been proven to have a signi cant child’s parent or guardian may be to clean hair care items and bedding effect on the incidence of head lice in notified that day by telephone or by 8,19,77 used by the individual with a school community over time. having a note sent home with the infestation. One study revealed that In addition, such screening has not child at the end of the school day head lice can transfer to pillowcases been shown to be cost-effective. In stating that prompt, proper treatment at night, but the incidence is low a prospective study of 1729 of this condition is in the best interest (4%). Changing just the pillowcase schoolchildren screened for head lice, of the child and his or her classmates. could minimize this risk of head lice only 31% of the 91 children with nits Common sense and calm should transmission.15 Only items that have had concomitant live lice. Only 18% prevail within a school when deciding been in contact with the head of of those with nits alone converted to how “contagious” an individual child the person with infestation in the 24 to having an active infestation during may be (a child with hundreds versus 78 48 hours before treatment should be 14 days of observation. Because of a child with 2 live lice). It may be fi considered for cleaning, given the fact the lack of evidence of ef cacy, prudent to check other children who that louse survival off the scalp routine classroom or schoolwide are symptomatic or who were most beyond 48 hours is extremely screening should be discouraged. likely to have had direct head-to-head unlikely. Such items may include Although children with at least 5 nits contact with the infested child. Some clothing, headgear, furniture, within 1 cm of the scalp were experts argue that because of the carpeting, and rugs. Washing, significantly more likely to develop an relatively high prevalence of head lice soaking, or drying items at infestation than were those with in young school-aged children, it may temperatures greater than 130°F will fewer nits (32% vs 7%), only one- make more sense to alert parents kill stray lice or nits. Furniture, third of the children at higher risk only if a high percentage of children carpeting, car seats, and other fabrics converted to having an active in a classroom are infested. Other or fabric-covered items can be infestation. School exclusion of experts feel strongly that these “alert vacuumed. Although head lice are children with nits alone would have letters” violate privacy laws, cause able to survive for prolonged periods resulted in many of these children unnecessary public alarm, and in chlorinated water, it is unlikely that missing school unnecessarily. In reinforce the notion that a head lice there is a significant risk of addition, head lice infestations have infestation indicates a failure on the transmission in swimming pools. One been shown to have low contagion in school’s part rather than study revealed that submerged head classrooms.79 The results of several a community problem.85 However, lice became immobile and remained descriptive studies have suggested studies examining the efficacy of alert in place on 4 people infested with that education of parents in letters are not available;

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 135, number 5, May 2015 e1361 consequently, some schools choose to SUMMARY OF KEY POINTS 6. Benzyl alcohol 5% can be used for design guidelines that they believe 1. No healthy child should be ex- children older than 6 months, or best meet the needs of their student cluded from school or allowed to malathion 0.5% can be used for population, understanding that miss school time because of head children 2 years or older in areas although a head lice infestation may lice or nits. Pediatricians may ed- where resistance to permethrin not pose a public health risk, it ucate school communities that or pyrethrins has been demon- may create a public relations dilemma no-nit policies for return to school strated or for a patient with for a school. should be abandoned. a documented infestation that has failed to respond to appropriately 2. It is useful for pediatricians to be Criteria for Return to School administered therapy with knowledgeable about head lice A child should not be restricted from permethrin or pyrethrins. Spinosad infestations and treatments school attendance because of lice, and topical ivermectin are newer (pediculicide and alternative ther- because head lice have low contagion preparations that might prove apies); they may take an active within classrooms.79 “No-nit” helpful in difficult cases, but the role as information resources for policies that exclude children until cost of these preparations should families, schools, and other com- all nits are removed may violate be taken into account by the pre- munity agencies. a child’s civil liberties and are best scriber (Table 1). 3. Unless resistance to these prod- addressed with legal counsel for 7. New products should be evaluated schools. However, most health care ucts has been proven in the com- for safety and effectiveness. professionals who care for children munity, 1% permethrin or 8. School personnel involved in de- agreethatno-nitpoliciesshould pyrethrins are a reasonable first tection of head lice infestation be abandoned.85 International choice for primary treatment of should be appropriately trained. guidelines established in 2007 for active infestations if pediculicide The importance and difficulty of the effective control of head lice therapy is required. correctly diagnosing an active infestations stated that no-nit 4. Carefully communicated instruc- head lice infestation should be policies are unjust and should be tions on the proper use of prod- emphasized. discontinued, because they are based ucts are important. Because on misinformation rather than current products are not com- 9. Head lice screening programs have fi objective science.86 The American pletely ovicidal, applying the not been proven to have a signi - Academy of Pediatrics and the product at least twice, at proper cant effect over time on the in- National Association of School intervals, is indicated if permeth- cidence of head lice in the school Nurses87 discourage no-nit policies rin or pyrethrin products are used setting and are not cost-effective. that exclude children from school. or if live lice are seen after pre- Parent education programs may be However, nit removal may decrease scription therapy per manu- helpful in the management of head diagnostic confusion, decrease the facturer’s guidelines. Manual lice in the school setting. possibility of unnecessary removal of nits immediately after LEAD AUTHORS retreatment, and help to decrease treatment with a pediculicide is Cynthia DiLaura Devore, MD, FAAP the small risk of self-reinfestation not necessary to prevent spread. Gordon E. Schutze, MD, FAAP and social stigmatization. In the school setting, nit removal COUNCIL ON SCHOOL HEALTH EXECUTIVE may be considered to decrease A school nurse familiar with lice COMMITTEE, 2014–2015 infestations, if present, can perform diagnostic confusion and social stigmatization. Jeffrey Okamoto, MD, FAAP, Chairperson a valuable service by rechecking Mandy Allison, MD, MSPH, MEd, FAAP a child’s head if requested to do so 5. If resistance to available OTC Richard Ancona, MD, FAAP by a parent. In addition, the school products has been proven in the Elliott Attisha, DO, FAAP nurse can offer extra help to families community, if the patient is too Cheryl De Pinto, MD, MPH, FAAP Breena Holmes, MD, FAAP of children who are repeatedly or young, or if parents do not wish to Chris Kjolhede, MD, MPH, FAAP chronically infested. In rare use a pediculicide, consider the Marc Lerner, MD, FAAP instances, it may be helpful to make manual removal of lice/nits by Mark Minier, MD, FAAP home visits or involve public health methods such as “wet-combing” or Adrienne Weiss-Harrison, MD, FAAP nurses if there is concern about an occlusive method (such as pe- Thomas Young, MD, FAAP whether treatment is being troleum jelly or Cetaphil cleanser), LIAISONS conducted effectively. Parent with emphasis on careful tech- Beth Mattey, MS, RN, NCSN – National Association of education by school health nique, close surveillance, and re- School Nurses professionals can reinforce similar peating for at least 3 weekly Mary Vernon-Smiley, MD, MPH, MDiv – Centers for goals for the medical home. cycles. Disease Control and Prevention

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