- Email: [email protected]
Dispelling the common myths about pediculosis
Dispelling the Common Myths . About Pediculosis . Ellen
Rudy Clore,
MSN,
RN, FNP
Pediculosis, the condition of being infested by head lice, is a major community health problem in the United States. Head lice, the most common species in humans, occupy considerable amounts of time and energy both within schools and the medical community. The condition creates school and family disturbances and personal embarrassment-consequences far exceeding its medical effects. Because parents are often embarrassed when they are informed about a head lice infestation, they often do not approach the subject with their health care providers. Pediatric nurse practitioners (PNPs) need to incorporate education relating the diagnosis and management of pediculosis in the well child visit. PNPs can dispel the common myths that have existed for so long to help open communication with parents and children to promote safe and proper treatment. Early detection is vital in preventing epidemics. J PEDIATR HEALTH CARE. (1989).
3, 28-33.
L
ice are external ectoparasites that are as aggravating as they are embarrassing. No one likes to think that their family may be infested with these parasites but year after year the incidence continues to increase. Unfortunately, head lice infestation is now a major community health problem. With the peak season from August through November, it has become a familiar occurrence in schools and day care centers. Last year, in many areas of the country, these infestations reached epidemic proportions, even forcing some schools to close and children whose parents cannot afford to purchase delousing medications are missing as much as 2 weeks of school with each infestation. Although head lice have been around for thousands of years, many myths persist. This misinformation interferes with safe and appropriate treatment. Pediatric nurse practitioners (PNPs) must be knowledgeable about this condition to dispel these myths as they educate and counsel families. Nurses also need to extend their services to day care and school settings in an effort to help the community manage the problem and prevent further epidemics. n
CHARACTERISTICS
AND
TRANSMISSION
1: Families who have head lice infestations practice poor hygiene and/or they are poor. Only children, not adults contract head lice.
MYTH
Ellen Rudy Clore is an assistant of Nursing, Orlando.
professor
Reprint
Clore,
requests:
University FL 32803.
28
Ellen Rudy
of Florida
College
at the University
MSN,
of Nursing,
RN,
of Florida College
FNP, Assistant
711 Lake Estelle Dr.,
Professor, Orlando,
FACT: PNPs need to inform parents that head lice have often been misassociated with poverty and poor hygienic practices. Washing a child’s hair on a regular basis will not affect infestation; the louse is capable of holding its breath for days if immersed in water below the heat level (140” F) necessary to kill it (Mauder, 1977). Anyone regardless of age can become infested although children between the ages of 5 and 12 years are most frequently the victims. It is estimated that between 6 and 12 million persons become infested each year and that approximately $367 million are spent attempting to control the problem (Lawson & Robinson, 1981). Approximately 59% of those persons with head lice also have another person in their family infested and infestation is higher among children who share lockers, ride school buses, and attend special education classes (Juranek, 1985). The incidence is higher in females, although there is no relationship between infestation rates and length of hair (Juranek, 1985). Black children are rarely infested although the reason for this is not known (Juranek, 1985). MYTH 2: Head lice are much like fleas; they hop, fly, and/or jump from person to person. FACT: Head lice are wingless, parasitic insects about l/s inch in length. They do not hop, fly, or jump but.they are capable of crawling up to 12 inches per minute. They range in color from light beige to black, have six claw-like appendages, and resemble a sesame seed in appearance. They live on the human scalp and must have a blood meal every 3 to 5 hours to survive (Taplin & Meinking, 1987). MYTH 3: People can “catch” head lice from their pet animals.
JOURNAL
OF PEDIATRIC
HEALTH
CARE
journal of Pediatric
Dispelling
Health Care
FACT: PNPs can assure parents that their household pet is not a host for head lice. Although there are approximately 3000 species of lice in the world, only three species infest human beings-head, body, and pubic lice. Transmission occurs by direct contact with an infested person or indirect contact with articles of clothing or grooming (e.g., hats, batting helmets, brushes, headphones, or ribbons) from the infested persons. Carpeting, pillows, bed linens, stuffed animals, car seats, and movie seats may also provide a source of transmission if lice from the infested person have fallen into the environment. Although head lice do not feed and breed on any other animals, it is theoretically possible that the louse from an infested person could “hitch” a ride to an uninfested person. MYTH 4: Itching (pruritus) is a definite sign of head lice infestation.
A
nyone regardless of age can become infested although children between the ages of 5 and 12 years are most frequently the victims.
During well child examinations, PNPs should alert parents to the common signs and symptoms of infestation. Head lice prefer the areas of the scalp behind the ears and at ;he nape of the neck. There the louse feeds by sucking blood from its host. The severity of symptoms caused by head lice is proportional to the degree of infestation (Taplin & Meinking, 1987). Saliva injected by the lice during feeding causes pruritus of the scalp, ears, and neck. However, parents need to be warned that not all persons are allergic to the saliva and therefore do not exhibit signs of itching. Restlessness and poor attention span in school may be the only clues of infestation (Clore, 1983; Ebomoyi, 1988). Although diagnosis may be made by direct observation of the louse, the most readily identifiable signs of head lice is the presence of nits or eggs. Pictures of nits and lice are readily available free of charge from many pharmaceutic companies. PNPs can acquire these resources and show parents exactly what to look for when checking their children. Nits are small, silvery, and oval; they are sometimes mistaken for dandruff, lint, or hair spray. The nits are attached by an adult female louse to the hair shaft with a cement-like substance. There, close to the scalp, they mature and hatch within 7 to 10 days. The hatched, immature FACT:
Myths About
TABLE 1 School environment head lice
n
Pediculosis
management
29
of
Educate school nurses, officials, and parents to: N Space hooks so coats will not touch each other and tuck hats into sleeves, pockets, or backpacks. m Discourage dress-up centers where children try on hats or clothes. Encourage the child to dress up in a costume at home and then come to school for special dress-up days. n Store nap-time supplies (mats, towels, pillows) in individual cubbies and send them home frequently for washing. n Vacuum carpet areas frequently. n Assign children to sit with the same person on the bus each day. n Discourage body contact and the sharing of personal items among children. Give each child his own personal comb during picture-taking times. n Institute screening programs three times per year. 9 Send children home if they are found to have an infestation. 9 Inform all parents that infestations have been found in the school and encourage them to check their children. l Incorporate a “no-nit” policy. Check the child for nits when he returns to school after he has been treated. n Encourage school personnel to check each other. n Discourage the use of sprays and fumigations.
nymph goes through several molting stages before maturing into an adult in about a week. Once hlly matured, mating begins almost immediately and the female begins to lay eggs within a day. During her 30-day life span, she may lay from 150 to 300 eggs (Morley, 1977). PNPs can teach parents to examine their children in natural light near a window with a magnifying glass. Nits must be differentiated from hair spray globules, lint, dandruff, sand, and hair casts, all of which can easily be brushed from the hair. The nits must be picked to be removed. Once diagnosis is determined, all persons known to have contact with the infested person should be examined. MYTH 5: Head lice can cause other diseases. FACT: PNPs can allay much anxiety in this area. Because head lice are parasites, and because of current concern about transmissible disease carried in the blood, many parents worry about whether they can transmit other diseases. Head lice were linked to typhus and relapsing fever historically (Altshuler & Kenney, 1986). At this point lice are not known to
30
n
Volume 3, Number 1 January-February 1989
Clore
TABLE
2
Resources COMPANY
PRODUCT
RESOURCE
TYPE OF MATERIAL
Burroughs Wellcome Co. 3030 Cornwallis Road Research Triangle Park, NC 27709
Nix
Pediculosis: Problem
LeemingIPacquin Division of Pfizer New York, NY 10017
Rid
Patient Care Pack Lice Infestation Update Is There a Louse in the House? Lester & Lucy’s Lousy Luck Lice Aren’t Nice
Booklet Booklet Filmstrip Filmstrip Game
Norcliff Thayer, Inc. P.O. Box 3842 Stanford, CT 06905
A-200 Pyrinate
Head Lice: Syndrome, Science, Solution All About Lice Head Lice: Treatment & Prevention Information for Parents
Film Filmstrip Instruction
Reed & Carnick One New England Ave. Piscataway, NJ 08854
Kwell R&C
Lice & Scabies from Infestation Lice are Insects, Too
Booklet Filmstrip
Quail Ridge Educational P.O. Box 340 Selma, OR 97538 Walt Disney Educational Media Company 500 S. Buena Vista St. Burbank, CA 91521
Media
Progress Report on a Community
The Head Lice Fact Book Head Lice Curriculum Activities Advice on Lice
to Disinfestation
Book
Video Slides
Booklet Booklet Video
REFERENCE:A. S. Benenson, (Ed.) Control of communicable diseases in man. American Public Health Association, 1015 Fifteenth DC 20005.Price $9.00. AGENCIES: The National Pediculosis Association, P.O. Box 149, Newton, MA 02101 (617) 449-6487. Dedicated to public education United States. The Centers for Disease Control, Atlanta, GA 30333
carry disease, but this subject is still being debated (Taplin & Meinking, 1987). Head lice may cause persistent itching of the scalp. The irritation leads to intense scratching, which sometimes results in secondary bacterial infections, such as impetigo. Other complications include lymphadenopathy, fever, and pyoderma. MYTH 6: Head lice often infest eyelashes and eyebrows. FACT: Head lice only infest the hair in the scalp area. Persons with lice or nits in the eyebrows and lashes are infested with pubic lice. PNPs examining children with such infestations should strongly suspect sexual abuse. MYTH 7: There is no way to prevent head lice epidemics in the school setting. FACT: Epidemics can be prevented in schools. Education and screening are the most important aspects of prevention. The National Pediculosis Association recommends schoolwide screenings three
sheets
St,, NW, Washington, and lice control
in the
times a year. September, the time for the first screening, has even been designated as National Pediculosis Month. Early detection and treatment of a few cases of infestation helps to prevent the spread throughout the school to epidemic proportions. The National Pediculosis Association has numerous written educational materials that can be sent home to assist parents in understanding and managing this condition. The PNP can consult with schools to set up screening programs, educate parent-teacher associations, and provide tips for prevention. These include such measures as listed in Table 1 and such resources as listed in Table 2. n
MANAGEMENT
The management of head lice involves a three-step process: application of a pediculicidal product, nit removal, and preparation of the environment. The chance for recurrent infestation is greatly reduced if parents perform all three steps. Education of each
Journal of Pediatric Health
n
TABLE
Dispelling
Care
3 Commonly
Pediculosis
31
used pediculicides
PRESCRIPTION
Prescription Kwell (Reed & Carnrick)
Nix
Nonprescription pyrethrin preparations Rid (Pfizer)
A-200 Pyrinate (Norcliff Thayer) R & C Shampoo (Reed & Carnrick) Pronto (Commerce Drug Co.) Triple X (Carter-Wallace, Inc.) NOTE: All shampoos are applied *Data from Meinking, T., Tapiin, Dermatology, 122, 267-271. Sigures not available.
ACTIVE INGREDIENT
KlUlNC
TIME *
OVICIDAL ACTIVITY*
Al’b’lJCAllON TIME
4-5 min
REPEAT AH’LICATION
Lindane 1% (shampoo)
3 hr 12 min
30%
Permethrin 1% (cream rinse)
10min
97%-99% 10 min
Pyrethrin 0.3% (shampoo)
10.5 min 26%
10 min
Recommended 7-10 days
Pyrethrin 0.33% (shampoo) Pyrethrin 0.3% (shampoo) Pyrethrin 0.33% (shampoo)
22.5 min 23%
10 min
18.6 min 25%
10 min
t
t
10 min
Recommended 7-l 0 days Recommended 7-10 days Recommended 7-10 days
Pyrethrin 0.3% (shampoo)
t
t
10 min
Recommended 7-10 days
Not necessary
Recommended 7-l 0 days
RElWtTED TOXIC FH%CTS
Minimal, if used according to directions Relatively safe if limited to one or two treatments Absorbed from skin and excreted in urine Nausea Vomiting Apiastic anemia Hypoplastic bone marrow Convulsions and death reported after ingestion or absorption of large amoon@ through skin None, other than a very low level of scalp irritation
Allergic reactions (burning, pruritus, stinging) Dermatitis Chemical conjunctivitis Same as Rid Same as Rid Same as Rid
Same as Rid
to dry hair. Nix is applied as a cream rinse after shampooing. All products except Kwell contain a nit comb. D., Kalter, D. and Eberle, M. (1986). Comparative efficacy of treatments for Pediculosis capitus infestations. Archives
step by the PNP is vital to help parents understand the importance of completing each step. Application
8: Only prescription medications are strong enough to kill lice and their nits. FACT: There are various well-known products on the market used to treat head lice. However, the degree to which they kill lice and nits varies. Many contain pyrethrins (Rid, R&C, A-200 Pyrinate,
MYTH
Myths About
of
Pronto, Triple X, and brands from large drug store chains) and are in the form of shampoos. These pediculicides are available as over-the-counter products. They are applied to dry hair for 10 minutes and must be reapplied in 7 to 10 days. Nix, containing permethrin 1% (synthetic pyrethrin), is in cream rinse form and has preventive properties, which protect persons against recurrent infestation for up to 2 weeks. It is available only by prescription as is Kwell, which contains lindane. Lin-
32
Volume 3, Number 1 huarv-February 1989
Clore
dane has received much publicity during the past few years because it is a controversial insecticide and was recently taken off the market for use in veterinary medicine. Table 3 reports the effectiveness of popular treatment products. PNPs need to share this information with parents as well as the actual procedure for treating the child safely. All products are effective lice killers, although the killing time for lindane is much slower than the others. Because ovicidal activity is not 100% for any of these products and all except permethrin have no residual activity, follow-up treatment is indicated. Residual activity is defined as death of nymphs hatching from viable nits 7 to 10 days after treatment.
T
he management of head lice involves a three-step process: application of a pediculicidal product, nit removal, and preparation of the environment.
MYTH 9: Dog shampoo or kerosene will kill lice infestations. FACT: Although there are reported cases of children being treated with dog shampoo and kerosene, these products have not been clinically tested on children for efficacy. Only those products approved for human use are recommended. Kerosene can burn and irritate the scalp; because it is flammable, a child could catch on fire. MYTH 10: A little antilouse medication is good, but a lot is better. FACT: PNPs should stress to parents that the manufacturer’s directions for application should be followed exactly. Overuse or misuse increases the potential for absorption into the bloodstream and thus the possibility of adverse effects. Only the hair and scalp area should be exposed to the medication. Therefore children should not be placed in the shower or bathtub but rather should be draped with towels as they lean their heads over the sink. Eyes should be protected, but if any pediculicide gets into the eyes, they should be flushed immediately with water. Persons applying the medication should protect themselves by wearing rubber gloves. MYTH 11: All persons coming in contact with the infested person should be treated. FACT All exposed persons should be examined but they should only be treated if they are found to
be infested. However, treatment products should not be used on infested infants; lice and nits should be hand picked or nit combed (NPA, 1987). Whether treating themselves or other family members, pregnant or nursing women should consult with their obstetrician or get someone else to treat their child. Persons allergic to ragweed should avoid pyrethrin and permethrin products. Nit Removal
Removal of nits is an important part of most currently available therapies. If nits are not removed, there is the possibility that remaining nits will hatch and reinfestation will occur. School districts in some states have a “no-nit” policy requiring that treated children be found free of both lice and nits before being allowed to return to school. Some pediculicides are sold with special fine-toothed combs to aid in the removal of these tiny eggs. PNPs should warn parents that nit combing is a tedious process and is sometimes uncomfortable for the child. MYTH 12: Nits further than l/4 inch from the scalp and those shed into the environment are nonviable. FACT: It is now known that nits further than l/4 inch from the scalp are capable of hatching (NPA, 1987). Because it is almost impossible to distinguish viable from nonviable nits with the naked eye, one must assume that all nits are capable of hatching. Although live lice cannot live off the host for longer than about 48 hours, nits shed into the environment are capable of hatching 7 TV 10 days later provided the temperature remains constant and in the normal range of the human host (Taplin & Meinking, 1987).
A
II exposed persons should be examined but they should only be treated if they are found to be infested.
MYTH 13: Nit combing is best accomplished when the hair is wet. FACT: PNPs should advise parents to towel dry the child’s hair because nit combs slip through wet hair and therefore do not snag the nits. Children complain of much discomfort if combing is performed when the hair is completely dry. Slightly damp hair best accomplishes the task of removing the nits. MYTH 14: Application of vinegar to the hair helps to loosen nit cement, making removal easier.
Journal of Pediatric Health
Dispelling
Care
FACT: Although this is a common practice, there is no research evidence that this is effective. Combing is the second step in the management process and PNPs can demonstrate to the parents how combing is most effectively performed. Hair should be parted into about four sections. Parents should start with one section at the top of the head. Starting at the top of the head is important because if nits fall to lower hairs they will be combed out as the comber moves down the hair. The teeth of the comb should be placed in a one inch strand of hair as close to the scalp as possible. Comb with a firm even motion away from the scalp all the way to the end of the strand. Pin back the strand with bobby pins or hair clips after the nits have been removed. Take each of the remaining sections of hair and repeat the combing procedure. Particular attention should be paid to the area above the ears and the nape of the neck because these are common infestation sites. The treated individual should then be checked daily for 10 to 14 days for evidence of lice and newly laid nits.
C
orrecting the common myths about pediculosis can assist PNPs to better educate families and school health officials.
The final step in the management process involves thoroughly cleaning all objects of potential transmission to remove lice and nits. PNPs can give the parent a written checklist to remind them of each task to be accomplished. MYTH 15: Fumigation of the entire house is the only method of assuring lice and nit elimination. FACT Spraying classrooms and homes is no longer recommended. The National Pediculosis Association and the Centers for Disease Control discourage the use of spraying because pediculicides are more toxic to humans and animals in their vaporous state (NPA, 1987). Parents should be reminded that the following measures need to be carried out to
Pediculosis
33
manage the infestation and prevent spread and recurrence. l All washable clothing, towels, and bed linens should be machine-washed in hot water and dried in a hot dryer for at least 20 minutes. Dry clean nonwashable items. n Carpets, car seats, pillows, stuffed animals, rugs, mattresses, and upholstered furniture need to be thoroughly vacuumed. n If parents cannot afford dry cleaning and do not have a vacuum cleaner, articles should be sealed in plastic bags for 14 days. n Soak combs, brushes, and hair accessories in lice-killing products for 1 hour or in boiling water for 10 minutes. n
SUMMARY
Because head lice infestations do not cause healththreatening problems, they are not often considered important enough to take the time and energy to promote prevention. Misinformation often interferes with prompt and safe management of this condition. Correcting the common myths about pediculosis can assist PNPs to better educate families and school health officials. n REFERENCES Altschuler, D. Z., & Kenney, L. R. (March, 1986). Pediculicide performance, profit, and the public health. Archives of&~matoloAv,
Preparing the Environment
Myths About
122, 259-261.
Clore, E. R. (1984). Lice: Ancient pest with new resistance. Pediatric
Nursing,
9, 347-350.
Ebomoyi, E. (March, 1988). Pediculosis capitis among primary school children in urban and rural areas of Kwara State, Nigeria. Journal ofSchool Health, 58, 101-103. Juranek, D. (1985). Pediculosis capitis in school children. In M. Orkin & H. Maibach (Eds.), Cutaneous infestations and insect bites (pp. 199-211). New York: Marcel Dekker. Lawson, D., & Robinson, R. (1981). Head lice: A community based epidemiological workshop. New York: Pfizer, Inc. Mauder, J. W. (February, 1977). Human lice: Biology and control. Royal Society of Health Journal, 97, 29-32. Morley, W. N. (July, 1977). Body infestations. Scottish Medical Journal, 22, 211-216. National Pediculosis Association. (1987). Dear parent. Newton MA: Author. Taplin, D., & Meinking, T. (1987). Head lice infestation: Biologly, diagnosti, managemmt (pp. 1-31). New York: Materia Medica/Creative Annex, Inc.
Rudy Clore,
MSN,
RN, FNP
Pediculosis, the condition of being infested by head lice, is a major community health problem in the United States. Head lice, the most common species in humans, occupy considerable amounts of time and energy both within schools and the medical community. The condition creates school and family disturbances and personal embarrassment-consequences far exceeding its medical effects. Because parents are often embarrassed when they are informed about a head lice infestation, they often do not approach the subject with their health care providers. Pediatric nurse practitioners (PNPs) need to incorporate education relating the diagnosis and management of pediculosis in the well child visit. PNPs can dispel the common myths that have existed for so long to help open communication with parents and children to promote safe and proper treatment. Early detection is vital in preventing epidemics. J PEDIATR HEALTH CARE. (1989).
3, 28-33.
L
ice are external ectoparasites that are as aggravating as they are embarrassing. No one likes to think that their family may be infested with these parasites but year after year the incidence continues to increase. Unfortunately, head lice infestation is now a major community health problem. With the peak season from August through November, it has become a familiar occurrence in schools and day care centers. Last year, in many areas of the country, these infestations reached epidemic proportions, even forcing some schools to close and children whose parents cannot afford to purchase delousing medications are missing as much as 2 weeks of school with each infestation. Although head lice have been around for thousands of years, many myths persist. This misinformation interferes with safe and appropriate treatment. Pediatric nurse practitioners (PNPs) must be knowledgeable about this condition to dispel these myths as they educate and counsel families. Nurses also need to extend their services to day care and school settings in an effort to help the community manage the problem and prevent further epidemics. n
CHARACTERISTICS
AND
TRANSMISSION
1: Families who have head lice infestations practice poor hygiene and/or they are poor. Only children, not adults contract head lice.
MYTH
Ellen Rudy Clore is an assistant of Nursing, Orlando.
professor
Reprint
Clore,
requests:
University FL 32803.
28
Ellen Rudy
of Florida
College
at the University
MSN,
of Nursing,
RN,
of Florida College
FNP, Assistant
711 Lake Estelle Dr.,
Professor, Orlando,
FACT: PNPs need to inform parents that head lice have often been misassociated with poverty and poor hygienic practices. Washing a child’s hair on a regular basis will not affect infestation; the louse is capable of holding its breath for days if immersed in water below the heat level (140” F) necessary to kill it (Mauder, 1977). Anyone regardless of age can become infested although children between the ages of 5 and 12 years are most frequently the victims. It is estimated that between 6 and 12 million persons become infested each year and that approximately $367 million are spent attempting to control the problem (Lawson & Robinson, 1981). Approximately 59% of those persons with head lice also have another person in their family infested and infestation is higher among children who share lockers, ride school buses, and attend special education classes (Juranek, 1985). The incidence is higher in females, although there is no relationship between infestation rates and length of hair (Juranek, 1985). Black children are rarely infested although the reason for this is not known (Juranek, 1985). MYTH 2: Head lice are much like fleas; they hop, fly, and/or jump from person to person. FACT: Head lice are wingless, parasitic insects about l/s inch in length. They do not hop, fly, or jump but.they are capable of crawling up to 12 inches per minute. They range in color from light beige to black, have six claw-like appendages, and resemble a sesame seed in appearance. They live on the human scalp and must have a blood meal every 3 to 5 hours to survive (Taplin & Meinking, 1987). MYTH 3: People can “catch” head lice from their pet animals.
JOURNAL
OF PEDIATRIC
HEALTH
CARE
journal of Pediatric
Dispelling
Health Care
FACT: PNPs can assure parents that their household pet is not a host for head lice. Although there are approximately 3000 species of lice in the world, only three species infest human beings-head, body, and pubic lice. Transmission occurs by direct contact with an infested person or indirect contact with articles of clothing or grooming (e.g., hats, batting helmets, brushes, headphones, or ribbons) from the infested persons. Carpeting, pillows, bed linens, stuffed animals, car seats, and movie seats may also provide a source of transmission if lice from the infested person have fallen into the environment. Although head lice do not feed and breed on any other animals, it is theoretically possible that the louse from an infested person could “hitch” a ride to an uninfested person. MYTH 4: Itching (pruritus) is a definite sign of head lice infestation.
A
nyone regardless of age can become infested although children between the ages of 5 and 12 years are most frequently the victims.
During well child examinations, PNPs should alert parents to the common signs and symptoms of infestation. Head lice prefer the areas of the scalp behind the ears and at ;he nape of the neck. There the louse feeds by sucking blood from its host. The severity of symptoms caused by head lice is proportional to the degree of infestation (Taplin & Meinking, 1987). Saliva injected by the lice during feeding causes pruritus of the scalp, ears, and neck. However, parents need to be warned that not all persons are allergic to the saliva and therefore do not exhibit signs of itching. Restlessness and poor attention span in school may be the only clues of infestation (Clore, 1983; Ebomoyi, 1988). Although diagnosis may be made by direct observation of the louse, the most readily identifiable signs of head lice is the presence of nits or eggs. Pictures of nits and lice are readily available free of charge from many pharmaceutic companies. PNPs can acquire these resources and show parents exactly what to look for when checking their children. Nits are small, silvery, and oval; they are sometimes mistaken for dandruff, lint, or hair spray. The nits are attached by an adult female louse to the hair shaft with a cement-like substance. There, close to the scalp, they mature and hatch within 7 to 10 days. The hatched, immature FACT:
Myths About
TABLE 1 School environment head lice
n
Pediculosis
management
29
of
Educate school nurses, officials, and parents to: N Space hooks so coats will not touch each other and tuck hats into sleeves, pockets, or backpacks. m Discourage dress-up centers where children try on hats or clothes. Encourage the child to dress up in a costume at home and then come to school for special dress-up days. n Store nap-time supplies (mats, towels, pillows) in individual cubbies and send them home frequently for washing. n Vacuum carpet areas frequently. n Assign children to sit with the same person on the bus each day. n Discourage body contact and the sharing of personal items among children. Give each child his own personal comb during picture-taking times. n Institute screening programs three times per year. 9 Send children home if they are found to have an infestation. 9 Inform all parents that infestations have been found in the school and encourage them to check their children. l Incorporate a “no-nit” policy. Check the child for nits when he returns to school after he has been treated. n Encourage school personnel to check each other. n Discourage the use of sprays and fumigations.
nymph goes through several molting stages before maturing into an adult in about a week. Once hlly matured, mating begins almost immediately and the female begins to lay eggs within a day. During her 30-day life span, she may lay from 150 to 300 eggs (Morley, 1977). PNPs can teach parents to examine their children in natural light near a window with a magnifying glass. Nits must be differentiated from hair spray globules, lint, dandruff, sand, and hair casts, all of which can easily be brushed from the hair. The nits must be picked to be removed. Once diagnosis is determined, all persons known to have contact with the infested person should be examined. MYTH 5: Head lice can cause other diseases. FACT: PNPs can allay much anxiety in this area. Because head lice are parasites, and because of current concern about transmissible disease carried in the blood, many parents worry about whether they can transmit other diseases. Head lice were linked to typhus and relapsing fever historically (Altshuler & Kenney, 1986). At this point lice are not known to
30
n
Volume 3, Number 1 January-February 1989
Clore
TABLE
2
Resources COMPANY
PRODUCT
RESOURCE
TYPE OF MATERIAL
Burroughs Wellcome Co. 3030 Cornwallis Road Research Triangle Park, NC 27709
Nix
Pediculosis: Problem
LeemingIPacquin Division of Pfizer New York, NY 10017
Rid
Patient Care Pack Lice Infestation Update Is There a Louse in the House? Lester & Lucy’s Lousy Luck Lice Aren’t Nice
Booklet Booklet Filmstrip Filmstrip Game
Norcliff Thayer, Inc. P.O. Box 3842 Stanford, CT 06905
A-200 Pyrinate
Head Lice: Syndrome, Science, Solution All About Lice Head Lice: Treatment & Prevention Information for Parents
Film Filmstrip Instruction
Reed & Carnick One New England Ave. Piscataway, NJ 08854
Kwell R&C
Lice & Scabies from Infestation Lice are Insects, Too
Booklet Filmstrip
Quail Ridge Educational P.O. Box 340 Selma, OR 97538 Walt Disney Educational Media Company 500 S. Buena Vista St. Burbank, CA 91521
Media
Progress Report on a Community
The Head Lice Fact Book Head Lice Curriculum Activities Advice on Lice
to Disinfestation
Book
Video Slides
Booklet Booklet Video
REFERENCE:A. S. Benenson, (Ed.) Control of communicable diseases in man. American Public Health Association, 1015 Fifteenth DC 20005.Price $9.00. AGENCIES: The National Pediculosis Association, P.O. Box 149, Newton, MA 02101 (617) 449-6487. Dedicated to public education United States. The Centers for Disease Control, Atlanta, GA 30333
carry disease, but this subject is still being debated (Taplin & Meinking, 1987). Head lice may cause persistent itching of the scalp. The irritation leads to intense scratching, which sometimes results in secondary bacterial infections, such as impetigo. Other complications include lymphadenopathy, fever, and pyoderma. MYTH 6: Head lice often infest eyelashes and eyebrows. FACT: Head lice only infest the hair in the scalp area. Persons with lice or nits in the eyebrows and lashes are infested with pubic lice. PNPs examining children with such infestations should strongly suspect sexual abuse. MYTH 7: There is no way to prevent head lice epidemics in the school setting. FACT: Epidemics can be prevented in schools. Education and screening are the most important aspects of prevention. The National Pediculosis Association recommends schoolwide screenings three
sheets
St,, NW, Washington, and lice control
in the
times a year. September, the time for the first screening, has even been designated as National Pediculosis Month. Early detection and treatment of a few cases of infestation helps to prevent the spread throughout the school to epidemic proportions. The National Pediculosis Association has numerous written educational materials that can be sent home to assist parents in understanding and managing this condition. The PNP can consult with schools to set up screening programs, educate parent-teacher associations, and provide tips for prevention. These include such measures as listed in Table 1 and such resources as listed in Table 2. n
MANAGEMENT
The management of head lice involves a three-step process: application of a pediculicidal product, nit removal, and preparation of the environment. The chance for recurrent infestation is greatly reduced if parents perform all three steps. Education of each
Journal of Pediatric Health
n
TABLE
Dispelling
Care
3 Commonly
Pediculosis
31
used pediculicides
PRESCRIPTION
Prescription Kwell (Reed & Carnrick)
Nix
Nonprescription pyrethrin preparations Rid (Pfizer)
A-200 Pyrinate (Norcliff Thayer) R & C Shampoo (Reed & Carnrick) Pronto (Commerce Drug Co.) Triple X (Carter-Wallace, Inc.) NOTE: All shampoos are applied *Data from Meinking, T., Tapiin, Dermatology, 122, 267-271. Sigures not available.
ACTIVE INGREDIENT
KlUlNC
TIME *
OVICIDAL ACTIVITY*
Al’b’lJCAllON TIME
4-5 min
REPEAT AH’LICATION
Lindane 1% (shampoo)
3 hr 12 min
30%
Permethrin 1% (cream rinse)
10min
97%-99% 10 min
Pyrethrin 0.3% (shampoo)
10.5 min 26%
10 min
Recommended 7-10 days
Pyrethrin 0.33% (shampoo) Pyrethrin 0.3% (shampoo) Pyrethrin 0.33% (shampoo)
22.5 min 23%
10 min
18.6 min 25%
10 min
t
t
10 min
Recommended 7-l 0 days Recommended 7-10 days Recommended 7-10 days
Pyrethrin 0.3% (shampoo)
t
t
10 min
Recommended 7-10 days
Not necessary
Recommended 7-l 0 days
RElWtTED TOXIC FH%CTS
Minimal, if used according to directions Relatively safe if limited to one or two treatments Absorbed from skin and excreted in urine Nausea Vomiting Apiastic anemia Hypoplastic bone marrow Convulsions and death reported after ingestion or absorption of large amoon@ through skin None, other than a very low level of scalp irritation
Allergic reactions (burning, pruritus, stinging) Dermatitis Chemical conjunctivitis Same as Rid Same as Rid Same as Rid
Same as Rid
to dry hair. Nix is applied as a cream rinse after shampooing. All products except Kwell contain a nit comb. D., Kalter, D. and Eberle, M. (1986). Comparative efficacy of treatments for Pediculosis capitus infestations. Archives
step by the PNP is vital to help parents understand the importance of completing each step. Application
8: Only prescription medications are strong enough to kill lice and their nits. FACT: There are various well-known products on the market used to treat head lice. However, the degree to which they kill lice and nits varies. Many contain pyrethrins (Rid, R&C, A-200 Pyrinate,
MYTH
Myths About
of
Pronto, Triple X, and brands from large drug store chains) and are in the form of shampoos. These pediculicides are available as over-the-counter products. They are applied to dry hair for 10 minutes and must be reapplied in 7 to 10 days. Nix, containing permethrin 1% (synthetic pyrethrin), is in cream rinse form and has preventive properties, which protect persons against recurrent infestation for up to 2 weeks. It is available only by prescription as is Kwell, which contains lindane. Lin-
32
Volume 3, Number 1 huarv-February 1989
Clore
dane has received much publicity during the past few years because it is a controversial insecticide and was recently taken off the market for use in veterinary medicine. Table 3 reports the effectiveness of popular treatment products. PNPs need to share this information with parents as well as the actual procedure for treating the child safely. All products are effective lice killers, although the killing time for lindane is much slower than the others. Because ovicidal activity is not 100% for any of these products and all except permethrin have no residual activity, follow-up treatment is indicated. Residual activity is defined as death of nymphs hatching from viable nits 7 to 10 days after treatment.
T
he management of head lice involves a three-step process: application of a pediculicidal product, nit removal, and preparation of the environment.
MYTH 9: Dog shampoo or kerosene will kill lice infestations. FACT: Although there are reported cases of children being treated with dog shampoo and kerosene, these products have not been clinically tested on children for efficacy. Only those products approved for human use are recommended. Kerosene can burn and irritate the scalp; because it is flammable, a child could catch on fire. MYTH 10: A little antilouse medication is good, but a lot is better. FACT: PNPs should stress to parents that the manufacturer’s directions for application should be followed exactly. Overuse or misuse increases the potential for absorption into the bloodstream and thus the possibility of adverse effects. Only the hair and scalp area should be exposed to the medication. Therefore children should not be placed in the shower or bathtub but rather should be draped with towels as they lean their heads over the sink. Eyes should be protected, but if any pediculicide gets into the eyes, they should be flushed immediately with water. Persons applying the medication should protect themselves by wearing rubber gloves. MYTH 11: All persons coming in contact with the infested person should be treated. FACT All exposed persons should be examined but they should only be treated if they are found to
be infested. However, treatment products should not be used on infested infants; lice and nits should be hand picked or nit combed (NPA, 1987). Whether treating themselves or other family members, pregnant or nursing women should consult with their obstetrician or get someone else to treat their child. Persons allergic to ragweed should avoid pyrethrin and permethrin products. Nit Removal
Removal of nits is an important part of most currently available therapies. If nits are not removed, there is the possibility that remaining nits will hatch and reinfestation will occur. School districts in some states have a “no-nit” policy requiring that treated children be found free of both lice and nits before being allowed to return to school. Some pediculicides are sold with special fine-toothed combs to aid in the removal of these tiny eggs. PNPs should warn parents that nit combing is a tedious process and is sometimes uncomfortable for the child. MYTH 12: Nits further than l/4 inch from the scalp and those shed into the environment are nonviable. FACT: It is now known that nits further than l/4 inch from the scalp are capable of hatching (NPA, 1987). Because it is almost impossible to distinguish viable from nonviable nits with the naked eye, one must assume that all nits are capable of hatching. Although live lice cannot live off the host for longer than about 48 hours, nits shed into the environment are capable of hatching 7 TV 10 days later provided the temperature remains constant and in the normal range of the human host (Taplin & Meinking, 1987).
A
II exposed persons should be examined but they should only be treated if they are found to be infested.
MYTH 13: Nit combing is best accomplished when the hair is wet. FACT: PNPs should advise parents to towel dry the child’s hair because nit combs slip through wet hair and therefore do not snag the nits. Children complain of much discomfort if combing is performed when the hair is completely dry. Slightly damp hair best accomplishes the task of removing the nits. MYTH 14: Application of vinegar to the hair helps to loosen nit cement, making removal easier.
Journal of Pediatric Health
Dispelling
Care
FACT: Although this is a common practice, there is no research evidence that this is effective. Combing is the second step in the management process and PNPs can demonstrate to the parents how combing is most effectively performed. Hair should be parted into about four sections. Parents should start with one section at the top of the head. Starting at the top of the head is important because if nits fall to lower hairs they will be combed out as the comber moves down the hair. The teeth of the comb should be placed in a one inch strand of hair as close to the scalp as possible. Comb with a firm even motion away from the scalp all the way to the end of the strand. Pin back the strand with bobby pins or hair clips after the nits have been removed. Take each of the remaining sections of hair and repeat the combing procedure. Particular attention should be paid to the area above the ears and the nape of the neck because these are common infestation sites. The treated individual should then be checked daily for 10 to 14 days for evidence of lice and newly laid nits.
C
orrecting the common myths about pediculosis can assist PNPs to better educate families and school health officials.
The final step in the management process involves thoroughly cleaning all objects of potential transmission to remove lice and nits. PNPs can give the parent a written checklist to remind them of each task to be accomplished. MYTH 15: Fumigation of the entire house is the only method of assuring lice and nit elimination. FACT Spraying classrooms and homes is no longer recommended. The National Pediculosis Association and the Centers for Disease Control discourage the use of spraying because pediculicides are more toxic to humans and animals in their vaporous state (NPA, 1987). Parents should be reminded that the following measures need to be carried out to
Pediculosis
33
manage the infestation and prevent spread and recurrence. l All washable clothing, towels, and bed linens should be machine-washed in hot water and dried in a hot dryer for at least 20 minutes. Dry clean nonwashable items. n Carpets, car seats, pillows, stuffed animals, rugs, mattresses, and upholstered furniture need to be thoroughly vacuumed. n If parents cannot afford dry cleaning and do not have a vacuum cleaner, articles should be sealed in plastic bags for 14 days. n Soak combs, brushes, and hair accessories in lice-killing products for 1 hour or in boiling water for 10 minutes. n
SUMMARY
Because head lice infestations do not cause healththreatening problems, they are not often considered important enough to take the time and energy to promote prevention. Misinformation often interferes with prompt and safe management of this condition. Correcting the common myths about pediculosis can assist PNPs to better educate families and school health officials. n REFERENCES Altschuler, D. Z., & Kenney, L. R. (March, 1986). Pediculicide performance, profit, and the public health. Archives of&~matoloAv,
Preparing the Environment
Myths About
122, 259-261.
Clore, E. R. (1984). Lice: Ancient pest with new resistance. Pediatric
Nursing,
9, 347-350.
Ebomoyi, E. (March, 1988). Pediculosis capitis among primary school children in urban and rural areas of Kwara State, Nigeria. Journal ofSchool Health, 58, 101-103. Juranek, D. (1985). Pediculosis capitis in school children. In M. Orkin & H. Maibach (Eds.), Cutaneous infestations and insect bites (pp. 199-211). New York: Marcel Dekker. Lawson, D., & Robinson, R. (1981). Head lice: A community based epidemiological workshop. New York: Pfizer, Inc. Mauder, J. W. (February, 1977). Human lice: Biology and control. Royal Society of Health Journal, 97, 29-32. Morley, W. N. (July, 1977). Body infestations. Scottish Medical Journal, 22, 211-216. National Pediculosis Association. (1987). Dear parent. Newton MA: Author. Taplin, D., & Meinking, T. (1987). Head lice infestation: Biologly, diagnosti, managemmt (pp. 1-31). New York: Materia Medica/Creative Annex, Inc.