Opinions of Members of the SC School Nurse Program Advisory Panel Regarding Evidence Based Management of Pediculosis capitis in the School Setting
Thanks to each of you for giving your opinions. On the next few posts (reading down), you will see summaries of answers given to the Survey Questions for Round 2, as well as the free text responses that you and your colleagues gave. I so appreciate the time you have given to consider the opinions and responses of your colleagues and to provide thoughtful answers to these important questions.
The items are presented as they were in Round 1, in a series of blog posts. You may need to click the “Next” button at the bottom of the page to view all of the posts for Round 2. You can also view the results as a PDF file downloadable from Google Docs.
Our next step is to confirm the agreement between Rounds 1 & 2, to see if consensus is present for items. There may also be some “tie-breaker” questions to settle.
Again, I thank you for your participation thus far, and I thank you in advance for your help in revising our exclusion policy.
Michelle L. Myer, MSN, RN, APRN, CPNP
SC DHEC Epidemiology Nurse Consultant
USC DNP Student
Question 1: Please indicate your agreement or disagreement with the following statements, as they relate to school exclusion guidance regarding pediculosis.
"…defined by presence of nits on the scalp" - agree if specified distance
Preventing days absent from school there must be excludable conditions.
Question 1: Pub Med’s definition of pediculosis is “the infestation of lice” not nits and lice. I would omit crawling. If they are alive, they will crawl. If they don’t they are dead. Why not just say: “Pediculosis may be defined as the presence of live lice…” The one word that could be argued is “only”. If we use “may be defined as…” it will give us somewhat of a leeway to work with. But the truth be known you either have them or you don’t.
Question 2: It is very difficult to “measure” a nit from the scalp. I would not require my nurses to measure.
Question 3: Here again - the true definition of pediculosis is “the infestation of lice.” not “the presence of live, crawling lice…and/or the presence of nits…” The phrase “that appear to be” is feasible. Most nurses can estimate 1/4” or 6 mm. But what if the parent treated the student the night before, nits will probably still be on the hair shaft. So are we going to say it is an infestation if the nits are that close?
Question 4: If you look hard enough, if the lice are on the scalp - you will see them. They may look like a grain of black sand and you see it move.
Question 5: Totally not - A definition is needed and necessary. It does need to be included in the excludable policies. The statement: “does not need to be identified …nor included” would not work.
The definition should include the presence of live, crawling lice AND the presence of immature brown nits close to the scalp.
The presence of live lice and nits close to scalp —I exclude. If no live lice -just nits that are not close to the scalp… I just request parents to remove remaining nits—-I do not exclude for this.
Question 2: A student in an ELEMENTARY SCHOOL or INTERMEDIATE SCHOOL (grades 1-5) is identified with live crawling lice and/or viable nits located 1 cm or closer to the scalp. Based upon your review of evidence, please indicate your agreement with the following school-based management options. The student should be:
Again we want to prevent the spread of infestations.
Question 1 - There are exceptions to all rules and this may be one of them. If it is a self contained class where there is frequent head to head contact in some form or other, yes, I would say exclude from the classroom immediately. Regular classroom should be a case by case situation. One where the teacher and nurse discuss options on how to keep the children from head to head contact. In the older age group, it is not as difficult, but the lower grades it may be difficult to keep children from head to head contact.
Question 2 - This is feasible as long as there is no head to head contact. Here again, I am in favor of nurse/teacher consultation to see if it would benefit the child and the classroom to either exclude or let stay until the end of the day.
Question 3 - I feel this would be very difficult for me to enforce. Some classrooms have hats for play time, they lie on the floor close to one another on mats and with blankets. This is a good recipe for infesting other students. And you have to realize, some students love to share their combs, brushes, hair accessories, etc
Immediate exclusion from the classroom helps to prevent spread at this age level.
I think it should be handled very carefully…so that the child is not targeted….if first time—-send home….if repeaters-have teacher choose activities that do not require headphones (for the whole class). The child does not need to be singled out.
Question 3: A student in a MIDDLE SCHOOL or HIGH SCHOOL (grades 6-12) is identified with live crawling lice and/or viable nits located 1 cm or closer to the scalp. Based upon your review of evidence, please indicate your agreement with the following school-based management options. The student should be:
Having a No-Nit Policy we must exclude.
Before I start commenting on the statements, how can we say whether or not the nits are viable?
Question 1 - I can’t agree with this. A student sleeps over at a friend’s home, contracts lice for the first time ever and goes to school and is excluded. That seems rather harsh. Now if it is a student that picks the live lice out of her hair and displays them on her desk and names them because she considers them her pets is different (I actually had a student do this). This student I would call parents/guardians and request they pick her up from school and treat as soon as they could. (Which I have done).
Question 2 - This is what I normally do. I talk to the student in private and explain to them how important it is to keep from spreading the insect and what they can do to help at home in order to get rid of the lice. If it is a repeat person, I will call the parent/guardian and gently ask questions on how they deal with the lice problem. I give them suggestions and if they feel they have done all they can, suggest they seek medical attention for the problem. If approached in the right way, most parents/guardians are appreciative of the advice.
Questions 3 - This could possibly be a recipe for disaster. Unless you teach the students how to keep from spreading the insects.
Policy should be consistent.
Older children can keep distance so as not to spread lice. There is not as much contact…counseling by school nurse and student, the notifying parent would be my choice for Middle School children.
Question 4: Please indicate your agreement or disagreement with each of the following options for readmission criteria for students excluded from school for pediculosis. A student may return to school, after identification of pediculosis:
I do not think the school should identify acceptable methods/products especially if the parent is told to use a less traditional method/product by their health care provider.
We have a no lice or nits policy. Students must go home for treatment and may return if they are lice and nit free.
I think the school identifying “acceptable products” (a general term like a specific pediculicide- is helpful in order to discourage use of non effective treatments (grease/oils), but actually, if the lice/nits are gone, they’re gone. (In my experience if they’re gone, the parent used something other than a suffocant or mechanical means.) Perhaps stating that grease/oil is effective in “slowing down” the lice to make them easier to see is misinterpreted by parents (as actually killing the lice), so I wonder if grease/oil should be mentioned at all when discussing with parents. If lice cannot be suffocated, the fact that it’s mentioned as an option is misleading. When we “identify” acceptable means other than what clinical research says is effective, we’re saying they are effective options. Are they, or not?? If we do indentify an acceptable treatment, do we need to have the parent show a package, etc.? (That is not really “proof”, so is it necessary? Aren’t we going to visually inspect, anyway?)
Question 1 - Yes, with the stipulation they follow the instructions, which usually say to retreat in approximately 7 days. And to examine the scalp once they come back to school after the first treatment.
Question 2 - There are heating combs, dyers and other mechanical instruments, I believe that kill the lice. Here again, Screen after the initial treatment and ask the parents to treat for lice again in approximately 7 days.
Question 3 - After the literature you presented, no way. These insects have learned how to cope with these products and they will survive.
Question 4 - There are herbal products on the market but from the literature these products are not very successful and it just defeats the purpose of trying to get rid of the bugs.
Question 5 - I have had parents tell me they treated their child and I examine the scalp and find just as many head lice as I had discovered the day before. I am not saying they didn’t treat the child, I am saying the insects were not killed. If we are to make a ruling on this situation, we need to help parents/guardians understand that not all products kill the lice and that our suggestions are approved through whatever organization we choose to go by. Whether it be the CDC or AAP.
Question 6 - This is not a good statement. The children that have head lice are miserable and scratch their heads. They sometimes scratch their heads so much they cause abrasions on their scalp, which in turn may distract the student from his/her studies.
I don’t think the district should recommend the product.
Nurse should check student to make sure no live lice(crawling) are present after safe treatment of lice .
Question 5: Please indicate your agreement or disagreement with each of the following options for screening of students who have been excluded for pediculosis prior to readmission to school.
Students may be readmitted following exclusion for pediculosis in the following circumstances:
See comments to previous question… I think the best verification of treatment is to inspect, if we are going to require it before re-entry. If we are not going to “require”, do we need to do a follow up inspection?
Must show proof of treatment and rechecked as clear for readmission.
Question 1 - This is the policy I try to follow. If I find live lice after the treatment, I will contact the parent and we will discuss other options for the student. I normally don’t exclude them for the day. I will let them attend class.
Question 2 - That is almost impossible to do. Trying to use a nit comb to comb the nits out especially in thick long hair is horrible. Follow the directions on the pediculicide and retreat within the specified time frame.
Question 3 - This is almost impossible to do. I have had experiences where the child was treated but was unable to get all the nits out the hair.
Question 4 - I would need at least confirmation from the parent. In our school district we have a standard letter that goes home stating that lice has been found and that treatment is necessary. After the initial treatment, the letter is to be returned with a signature from the parent stating the date of the recommended second treatment.
Question 5 - This is basically how we do it, but we include a statement where the parent fills in the recommended second treatment date.
Question 6 - This would be workable also.
Question 7 - Some parents would take advantage of this and choose not to treat their children.
Question 8 - This goes back to if a child has head lice so bad they are constantly scratching their head, they will eventually scratch until they draw blood and the child is even more miserable and unable to concentrate on their schoolwork.
There will be cases of head lice that are so severe that ALL of the nits cannot be removed at once. I think the key is that there are no live lice, and no immature brown nits, and that the nurse sees progress with nit removal with every screening, whether that screening be daily or weekly.
Students should be treated and checked by nurse in confidential manner. Some parents will no or do not think that nit removal is important….but it is very important. Educating parents and students is very important. Do not exclude student because of lack of parent knowledge or effort. Treatment is a must too.
Question 6: Please indicate your agreement or disagreement with each of the following statements regarding re-screening of students previously identified with pediculosis in the school setting.
Parents are advised to rescreen and/or retreat after a week.
I think rescreening should be recommended but definitely not required.
Question 1 - I do try to rescreen but I feel it should not be just the ones that were excluded. I think it should be a rescreening across the board. I also feel it important to screen the day after the student returns to class.
Question 2 - This I do agree with, but I feel it necessary to screen the student the day after treatment just in case.
Question 3 - I don’t see how that would keep infestations at a minimal.
Question 4 - That will not work at all.
The nurse follows up, documents, and closes the case, or if necessary, reminds parents of the second treatment.
It is not a serious health condition, but can lead to Infections and lost school days (and low self-esteem). Lice is not a onetime treat and it is gone….it is a month long process of checking /treating to totally get rid of it.
Question 7: Please indicate your agreement or disagreement with each of the following statements regarding subsequent exclusion of students previously identified with pediculosis in the school setting.
Parents are advised to rescreen and treat accordingly.
Question 1 - This is good in theory but how do we enforce it? It is common knowledge that lice do not cause disease, it is more of a pesky situation. The only time it would be detrimental to a student is when the student claws at their scalp and causes sores that may get infected from the bacteria harbored underneath their fingernails.
Question 2 - The “and/or” phrase is what kills the agreement on my part. Just because you see a nit 1/4 inch from the scalp does not mean there is a live louse (lice).
Question 3- Here again the “and/or” phrase kills the agreement on my part.
Question 4 - How do we know the student was treated in the first place if we don’t screen after readmission? How do we know how they were treated if they are not requested to send in the information? How can we make alternative suggestions, if we just send a note home stating “it is in the best interest of the child to be treated for head lice”?
Parental contact is necessary to ensure effective treatment.
This is part of the educating parents issue.. Live crawling lice do require exclusion….and continued parent education.