Managing head lice in the school setting Melanie Ayala, RN Cotulla ISD District Nurse

What are Head Lice? Head lice are tiny gray to brown insects about the size of a sesame seed that live in human hair and must feed on human blood to live. They lay tiny white oval-shaped eggs about the size of a knot in a thread, called nits that glue to each strand of hair close to the scalp. Although it is hard to see head lice, a person can see the nits if they look closely. Nits are most often found in the hair behind the ears and at the back of the head and neck. The first sign of lice is itching of the head which is caused by the bite of the head lice.

Head lice

How do You Get Head Lice? Head lice happen mostly with elementary school- aged children. Children get lice from other children through head to head contact during play or sports or nap time and most often in school settings. Sometimes sharing combs, hats or school lockers with a louse infested child can spread head lice. You can’t spread nits…only live lice. Head lice do not spread disease. Any child can get head lice. It doesn’t matter where they live or go to school, boy or girl, black, white or brown. It doesn’t mean the child is sick or unclean. It certainly doesn’t mean they have bad parents. Children get head lice almost as much as the common cold. Millions get it at least once a year.

How Do You Get Rid of Head Lice? The Texas Department of State Health Services recommends the following treatment for head lice and nits: Use an over-the-counter FDA-approved shampoo treatment that you find at the drug or grocery store. Follow the directions on the packaging exactly. Remove as many nits as possible with a special nit comb that comes with the head lice treatment. Treat your home at the same time you treat your child. Do the following: Soak combs and brushes in some of the lice shampoo for 1 hour or in very, very hot water for 5-10 minutes. Wash sheets, blankets and other bedding in the hottest setting of water in the washing machine. Dry-clean non-washable items or seal these items in a plastic bag for 1 week. Vacuum furniture, carpets and mattresses thoroughly. Treat hair for a second time after 7 days (or follow the manufacturer of the lice treatment’s instructions) to make sure that you kill any lice that may have hatched from nits that might have been missed during the combing, before they lay eggs. There is no need to cut hair. Lice like to crawl on short hair just as much as long hair and they need the same amount of treatment.

How Do You Keep Lice From Coming Back? Teach family members to recognize nits and how lice is spread and check everyone’s hair periodically. If you find lice, follow the recommended treatment closely. It should be reported to the school nurse, who can check close contacts. Remind children not to share combs, brushes, hair accessories, headphones, hats, clothing, bedding, coats and so forth. Ask the teacher if there is a space to keep jackets, hats and other personal items separate for each child. Ask what you can do to help.

THE LAW AS IT RELATES TO HEAD LICE: There is no statue in Texas that addresses excluding children with head lice from school. Lice are not a public health threat, they do not carry disease.  Therefore, the Department of State Health Services does not monitor or track cases of head lice.

“No-Nit” Policies A “no nit” policy is one that excludes students from school based on the presence of lice eggs whether or not live lice are present. The Department of State Health Services (DSHS) does not recommend a “no nit” policy. They do recognize, however, that school districts may adopt one as a local option. DSHS does not have authority to impose a set policy regarding head lice on districts. DSHS does, however, urge school districts to ensure that its policy does not cause children to miss class unnecessarily or encourage the embarrassment and isolation of students who suffer from repeated head lice infestations. Head lice infestation is a social issue not a health threat. “No nit” policies place a disproportionate amount of emphasis on head lice management than on real health concerns which should be a higher priority. This over-emphasis can lead to unproductive use of time by school staff and parents, missed classes, unnecessary absences, and parents missing work.

Cotulla isd local policy Screening Procedure: Unwarranted mass screenings are disruptive to student and teacher class time. They increase the potential for lice phobia and prophylactic use of pediculicides. They also take away from the nurses’ ability to address the needs of the more physically or mentally disabled student. If any lice, eggs and/or nits are found by the teacher or other school district employee, the student should be sent to the school nurse for further examination. Once the school nurse has confirmed an active case of head lice parents will be notified. Parents will be educated about the needed treatment, how to identify head lice infestations, how to delouse bedding and personal articles, and how to prevent transmission.

Cotulla isd local policy Screening Procedure: Classroom or school-wide notifications may serve to increase public alarm and bring undue attention to children with louse infestations. Such notifications disrupt school productivity and may strain school resources. To prevent this, as well as the injudicious use of pesticides on unaffected classmates, parents of infested children will be the only individuals notified if a louse infestation is confirmed.

Cotulla isd local policy Parent/Guardian Notification: Upon notification that their child has head lice, parents will be encouraged to pick up their child from school and begin treatment as soon as possible. Careful consideration will be given to develop alternatives for children whose families lack transportation or who for some reason are unable to pick up their child from school. The school district does not follow a “no-nit”policy.

Cotulla isd local policy Readmission Criteria: Students returning to school after treating with an FDA-approved, medicated treatment should be examined before they return to class. If signs of re-infestation are noted, school health personnel will review with the parents or guardians the correct procedures for treatment, nit-removal, and delousing the household environment. Frequent infestations and excessive absences may be a sign of other problems, and the school may chose to seek assistance from a local public health department or appropriate local regulatory and/or social service agency. If the inability of a student’s family to purchase pediculicide is an issue, collaboration between the school system and local community service agencies may provide a resource for funds. For those who have Medicaid or health insurance, many pediculicides, both over the counter and prescription, are covered. They do require a written prescription from a physician, even over the counter brands. Generic, less expensive store brands are available as well.

CDC Students diagnosed with live head lice do not need to be sent home early from school; they can go home at the end of the day, be treated, and return to class after appropriate treatment has begun. Nits may persist after treatment, but successful treatment should kill crawling lice. Head lice can be a nuisance but they have not been shown to spread disease. Personal hygiene or cleanliness in the home or school has nothing to do with getting head lice. Both the American Association of Pediatrics and the National Association of School Nurses advocate that "no-nit" policies should be discontinued. "No-nit" policies that require a child to be free of nits before they can return to schools should be discontinued for the following reasons: Many nits are more than ¼ inch from the scalp. Such nits are usually not viable and very unlikely to hatch to become crawling lice, or may in fact be empty shells, also known as casings. Nits are cemented to hair shafts and are very unlikely to be transferred successfully to other people. The burden of unnecessary absenteeism to the students, families and communities far outweighs the risks associated with head lice. Misdiagnosis of nits is very common during nit checks conducted by nonmedical personnel.

NASN Position statement It is the position of the National Association of School Nurses that the management of pediculosis (infestation by head lice) should not disrupt the educational process. No disease is associated with head lice, and in- school transmission is considered to be rare.  When transmission occurs, it is generally found among younger-age children with increased head-to- head contact (Frankowski & Bocchini, 2010).    Children found with live head lice should remain in class, but be discouraged from close direct head contact with others. The school nurse should contact the parents to discuss treating the child at the conclusion of the school day (Frankowski & Bocchini, 2010).  Students with nits only should not be excluded from school (American School Health Association, 2005, Frankowski & Bocchini, 2010, Pollack, Kiszewski & Spielman, 2000), although further monitoring for signs of re-infestation is appropriate. It may be appropriate to screen other children who have had close head-to- head contact with a student with an active infestation, such as household family members, but classroom-wide or school-wide screening is not merited (Andresen & McCarthy, 2009). In cases that involve head lice, as in all school health issues, it is vital that the school nurse prevent stigmatizing and maintain the student’s privacy as well as the family’s right to confidentiality (Gordon, 2007). 

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