Treatment of Children With Head Lice in the School Setting Reviewed

From Medscape Medical News

Laurie Barclay, MD

July 26, 2010 — Current diagnosis, treatment protocols, and management guidelines regarding children with head lice in the school setting are presented in a clinical report posted online July 26 and in the August print issue of Pediatrics.

"Head lice infestation is associated with limited morbidity but causes a high level of anxiety among parents of school-aged children," write Barbara L. Frankowski, MD, MPH, and Joseph A. Bocchini Jr, MD, from the Council on School Health and Committee on Infectious Diseases, 2006-2010. "Since the 2002 clinical report on head lice was published by the American Academy of Pediatrics, patterns of resistance to products available over-the-counter and by prescription have changed, and additional mechanical means of removing head lice have been explored. 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."

The reference standard for diagnosing head lice is finding a live louse on the head, although infestation can also be diagnosed by using a louse comb or by observation of eggs at the nape of the neck or behind the ears, within 1 cm of the scalp.

Despite the impossibility of preventing all head lice infestations, children should be taught not to share personal items such as combs, brushes, and hats.

"Never initiate treatment unless there is a clear diagnosis of head lice," the review authors write. "The ideal treatment for lice would be completely safe, free of harmful chemicals, readily available without a prescription, easy to use, and inexpensive. When recommending a treatment, paediatricians should take into account effectiveness and safety, local patterns of resistance (if known), ease of use, and cost."

Specific Recommendations

Specific recommendations regarding current diagnosis, management, and treatment protocols for children with head lice in the school setting include the following:

* Head lice should not be a reason for an otherwise healthy child to be excluded from or kept absent from school. No-nit policies for return to school should therefore no longer be enforced.
* Pediatricians should know how to manage and treat head lice infestations so that they can actively inform families, schools, and other community agencies.
* For treatment of active infestations, 1% permethrin or pyrethrins are recommended unless resistance to these medications has been proven in the community.
* School staff and parents should be given detailed instructions on the proper use of recommended treatments. Current permethrin or pyrethrin products are not completely ovicidal, necessitating that they be applied at least twice at proper intervals. This is also recommended if live lice persist after treatment with malathion. To prevent spread, manual removal of nits is not necessary immediately after pediculicide therapy. However, nit removal may be considered in the school setting to reduce diagnostic confusion.
* Feasible alternatives to use of pediculicide may include "wet-combing" or an occlusive method, such as petroleum jelly or a mild skin cleanser. Repetition for at least 2 weekly cycles, using careful technique, is needed. Suitable indications for these therapeutic options include proven resistance to available over-the-counter products in the community, a patient too young to use a pediculicide, or parental desire not to use a pediculicide.
* For children older than 6 months, benzyl alcohol 5% can be used in areas shown to have resistance to permethrin or pyrethrins or in patients with proven infestation refractory to appropriately administered treatment with permethrin or pyrethrins. In these situations, children at least 2 years old may be treated with malathion 0.5%.
* Safety and efficacy testing are recommended for new products.
* Appropriate training regarding the importance and difficulty of correctly diagnosing an active head lice infestation is needed for school personnel involved in detecting head lice infestation. School officials should review lice-related policies to ensure that this goal is achieved.
* Head lice screening programs have not been shown to be cost effective, nor have they been demonstrated to significantly reduce the incidence of head lice in the school setting with time. To manage head lice in the school setting, however, parent education programs may be helpful.

"The potential for misdiagnosis and the resulting improper use of pediculicides raise concerns about unsafe use of these products, specifically when no lice are present or when products are used excessively," the review authors write. "In addition, the emergence of resistance to available products and the development of new products, many without proof of efficacy or safety, call for increased physician involvement in the diagnosis and treatment of head lice."

"Optimal treatments are safe and effective, rapidly pediculicidal, ovicidal, easy to use, and affordable and incorporate a resistance-prevention strategy," the review authors conclude. "Because lice infestation is so benign, treatments must prove safe to ensure that the adverse effects of therapy are not worse than the infestation."

Pediatrics. Published online July 26, 2010.