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AMERICAN ACADEMY OF PEDIATRICS
CLINICAL REPORT
Guidance for the Clinician in Rendering Pediatric Care Barbara L. Frankowski, MD, MPH; Leonard B. Weiner, MD; the Committee on School Health; and the Head Lice
ABSTRACT.
Head lice infestation is associated with
from the scalp every few hours. This saliva may little morbidity but causes a high level of anxiety among
create an itchy irritation. With a first case of head parents of school-aged children. This statement attempts
lice, itching may not develop for 4 to 6 weeks, be- to clarify issues of diagnosis and treatment of head lice
cause it takes time to develop a sensitivity to louse and makes recommendations for dealing with head lice
saliva. Head lice usually survive for less than 1 day in the school setting.
away from the scalp at normal room temperature,and their eggs cannot hatch at an ambient tempera- ABBREVIATION. FDA, Food and Drug Administration.
INTRODUCTION
CLINICAL DISEASE
Head lice (Pediculosis capitis) infestation is Headlice,unlikebodylice,donottransmitany disease agents.3 Itching may develop in a sensitized dren 3 to 12 years of age; approximately 6 to individual. Rarely, an individual may develop impe- 12 million have infestations each year. Head lice are tigo and local adenopathy from scratching.
not a health hazard or a sign of uncleanliness and arenot responsible for the spread of any disease. The EPIDEMIOLOGY
most common symptom is itching. Individuals with Head lice are most common in children 3 to 12 head lice infestation may scratch the scalp to allevi- years of age. All socioeconomic groups are affected.
ate itching, and there rarely may be secondary bac- Infestations in the United States are less common in terial skin infection. Head lice are the cause of much blacks than in individuals of other races, most likely embarrassment and misunderstanding, many unnec- because blacks have oval-shaped hair shafts that are essary days lost from school and work, and millions harder for lice to grasp. Head lice in Africa have adapted claws for grasping this type of hair.2 Head ETIOLOGIC AGENT
lice infestation is not significantly influenced by hairlength or by frequent brushing or shampooing. How- The adult louse is 2 to 3 mm long (the size of a ever, in the United States, where daily brushing is sesame seed) and usually pale gray, although color routine, infested individuals rarely have more than a may vary. The female lives up to 3 to 4 weeks and dozen live lice, whereas individuals in cultures with lays approximately 10 eggs, or nits, a day. These tiny different grooming practices often have a hundred or eggs are firmly attached to the hair shaft close to the more live lice. Lice cannot hop or fly; they crawl.
scalp with a glue-like substance produced by the Transmission in most cases occurs by direct contact louse. Viable nits camouflaged with pigment to with the head of another infested individual.4 Indi- match the hair color of the infested person are most rect spread through contact with personal belong- easily seen at the posterior hairline. Empty nit cas- ings of an infested individual (combs, brushes, hats) ings are easier to see, appearing white against darker is much less likely but cannot be excluded. Lice hair. The eggs are incubated by body heat and hatch found on combs are likely to be injured or dead,5 and in 10 to 14 days. Once the eggs hatch, nymphs leave a healthy louse is not likely to leave a healthy head.6 the shell casing, grow for about 9 to 12 days, andmate, and then females lay eggs. If not treated, this DIAGNOSIS
cycle may repeat itself every 3 weeks.1 While thelouse is living on the head, it feeds by injecting small The gold standard for diagnosing head lice is find- amounts of saliva and taking tiny amounts of blood ing a live louse on the head. This can be difficult,because the louse can crawl 6 to 30 cm per minute.
The tiny eggs, or nits, may be easier to spot, espe- The recommendations in this report do not indicate an exclusive course of cially at the nape of the neck or behind the ears, treatment or serve as a standard of medical care. Variations, taking into within 1 cm of the scalp. It is important not to con- account individual circumstances, may be appropriate.
PEDIATRICS (ISSN 0031 4005). Copyright 2002 by the American Acad- fuse nits with dandruff, hair casts, or other hair debris; nits are more difficult to remove because they are “glued” on. It is also important not to confuse cause allergic reactions in individuals with plant al- live nits with dead or empty egg cases. Among pre- lergies. The product is a cream rinse applied to hair sumed “lice” and “nits” submitted by physicians, that is first shampooed with a nonconditioning nurses, teachers, and parents to a laboratory for iden- shampoo and then towel dried. It is left on for 10 tification, many were found to be artifacts such as minutes and then rinsed off, and it leaves a residue dandruff, hairspray droplets, scabs, dirt, or other on the hair that is designed to kill nymphs emerging insects (eg, aphids blown by the wind and caught in from the 20% to 30% of eggs not killed with the first the hair).7 In general, nits found more than 1 cm from application.10 However, it is suggested that the ap- the scalp are unlikely to be viable, but some research- plication be repeated if live lice are seen 7 to 10 days ers in warmer climates have found viable nits farther later. Some experts recommend routine retreat- from the scalp.2 A viable nit will develop an “eye ment.15 Resistance to 1% permethrin has recently spot” evident on microscopic examination several been reported,16–18 but the prevalence of this resis- PREVENTION
It is probably impossible to totally prevent head Lindane (Kwell [Reed & Carnick, Jersey City, NJ]) lice infestations. Young children come into close is an organochloride that has central nervous system head-to-head contact with each other frequently. It is toxicity in humans if used incorrectly; several cases prudent for children to be taught not to share per- of severe seizures in children using lindane have sonal items such as combs, brushes, and hats. In been reported.1,19–22 It is available only by prescrip- environments where children are together, adults tion as a shampoo that should be left on for no more should be aware of the signs and symptoms of head than 10 minutes with repeated application in 7 to 10 lice infestation, and affected children should be days. It has low ovicidal activity (30% to 50% of eggs treated promptly to minimize spread to others.
are not killed10), and resistance has been reportedworldwide for many years.23,24 For these reasons, it TREATMENT
Pediculicides
Pyrethrins Plus Piperonyl Butoxide The organophosphate (cholinesterase inhibitor) Manufactured from natural extracts from the chry- 0.5% malathion (Ovide [Medicis, Phoenix, AZ]) has santhemum, pyrethrins plus piperonyl butoxide recently been reintroduced to the US market. It is (RID [Bayer, Morristown, NJ], A-200 [Hogill Phar- available only by prescription as a lotion that is macetical Corp, Purchase, NY], R & C [GlaxoSmith- applied to the hair, left to air dry, then washed off Kline, Middlesex, United Kingdom] Pronto [Del Lab- after 8 to 12 hours. Malathion has high ovicidal ac- oratories, Uniondale, NY], Clear Lice System [Care tivity,10,25 but the product should be reapplied if live Technologies, Darien, CT]), are neurotoxic to lice but lice are seen in 7 to 10 days. The major concerns are have extremely low mammalian toxicity. The labels the high alcohol content of the product, making it warn against possible allergic reaction in patients highly flammable, and the risk of severe respiratory who are sensitive to ragweed, but modern extraction depression if accidentally ingested. For these rea- techniques minimize the chance of product contam- sons, it should be used with extreme caution in the ination, and reports of true allergic reactions are treatment of only those cases in which resistance to rare.8 However, pyrethrins should be avoided in per- sons allergic to chrysanthemums. These products aremostly shampoos that are applied to dry hair and left Topical Reactions
on for 10 minutes before rinsing out. These and allother topical pediculicides should be rinsed from the Itching or mild burning of the scalp caused by hair over a sink rather than in the shower or bath to inflammation of the skin in response to topical ther- limit exposure and with cool rather than hot water to apeutic agents can persist for many days after lice are minimize absorption attributable to vasodilitation.9 killed and is not a reason for retreatment. Topical None of these natural pyrethrins are totally ovicidal corticosteroids and oral antihistamines may be ben- (newly laid eggs do not have a nervous system for eficial for relieving these signs and symptoms.
several days); 20% to 30% of the eggs remain viableafter treatment.10 This necessitates a second treat- Other Topical Agents
ment 7 to 10 days later to kill newly emerged nymphs hatched from eggs that survived the first Five percent permethrin (Elimite [Allergan, Irvine, treatment. Resistance of adult lice to these products CA]) is available by prescription only as a cream usually applied overnight for scabies. It has anecdot-ally been recommended for the treatment of head lice that appear to be recalcitrant to other treatments; it Manufactured as a synthetic pyrethroid, 1% per- should be applied to the scalp and left on for several methrin (Nix [Pfizer Consumer Health Care Group, hours or overnight,13 then rinsed off. No case-control New York, NY]) is currently the recommended treat- studies have reported efficacy to date. One study ment of choice for head lice.12–14 It has even lower suggested that lice resistant to 1% permethrin will mammalian toxicity than do pyrethrins and does not not succumb to higher concentrations.18 It is not currently approved by the Food and Drug Adminis- that the viscous substance obstructs the respiratory tration (FDA) for use as a pediculicide.
spiracles of the adult louse, blocking efficient airexchange, as well as the holes in the operculum of the eggs.32 Another interpretation is that the intense, This product is available by prescription only as a daily attention to hair grooming results in removal of lotion (Eurax [Westwood-Squibb Pharmaceuticals, all the lice and nits. Hair pomades are easier to Buffalo, NY]) usually used to treat scabies. A single remove but may not kill eggs, and treatment should study showed it to be effective against head lice be repeated weekly for 4 weeks.33 Other occlusive when applied to the scalp and left on for 24 hours substances have been suggested (mayonnaise, tub before rinsing out.26 Safety and absorption in chil- margarine, herbal oils, olive oil), but to date only dren, adults, and pregnant women have not been anecdotal information is available concerning effi- evaluated. It is not currently approved by the FDA Other Agents
Oral Agents
Flammable or toxic substances, such as gasoline or kerosene, should never be used. Products intendedfor animal use should not be used to treat head lice in This antibiotic sometimes called cotrimoxazole (Septra [GlaxoSmithKline, Middlesex, United King-dom], Bactrim [Roche Laboratories, Nutley, NJ]), Manual Removal
used in otitis media doses, has been cited as effective Removal of nits after treatment with a pediculicide against head lice.27 This antibiotic is postulated to kill is not necessary to prevent spread, because only live the symbiotic bacteria in the gut of the louse or lice cause an infestation. Individuals may want to perhaps to have a direct toxic effect on the louse. A remove nits for aesthetic reasons or to decrease di- recent study indicated increased effectiveness of this agnostic confusion. Because none of the pediculi- antibiotic in combination with permethrin 1% when cides are 100% ovicidal, manual removal of nits (es- compared with permethrin 1% or sulfamethoxazole/ pecially the ones within 1 cm of the scalp) after trimethoprim alone; however, the treatment groups treatment with any product is recommended by were small.28 Rare severe allergic reactions (Stevens- some. Nit removal can be difficult and tedious.34 Johnson syndrome) to this medication make it a po- Fine-toothed “nit combs” are available to make the tentially undesirable therapy if alternatives exist.1 It process easier.35,36 Studies have shown that lice re- is not currently approved by the FDA for use as a moved by combing and brushing are damaged and rarely survive.5 In the United Kingdom, communitycampaigns have been launched using “bug buster” combs and ordinary shampoo.37 Everyone is in- This product (Stromectal [Merck & Co., West structed to shampoo hair twice a week for 2 weeks Point, PA]) is an anthelmintic agent structurally sim- and vigorously comb out wet hair each time. The wet ilar to the macrolide antibiotics but without antibac- hair seems to slow down the lice. Combing dry hair terial activity. An oral dose of 200 micrograms/kg, does not seem to have the same effect; a study con- repeated in 10 days, has been shown to be effective ducted in Australia in which children combed their against head lice.29 If ivermectin gets past the blood- hair daily at school with an ordinary comb deter- brain barrier, it blocks essential neural transmission; mined that this was not effective.38 Some postulated young children may be at higher risk for this adverse that vigorous dry combing or brushing in close quar- drug reaction. Therefore, ivermectin should not be ters may even spread lice by making them airborne used for children who weigh less than 15 kg.30,31 It is via static electricity. Battery-powered “electronic” not currently approved by the FDA as a pediculicide.
louse combs that resemble small “bug zappers”39 orthose with oscillating teeth would seem to offer little “Natural” Products
advantage, if any, over a well-designed traditional Several products are marketed by health food louse comb. The teeth of these devices may not ef- stores for treatment of head lice and are in wide use.
fectively reach to the scalp and do not kill or remove As natural products, they are not required to meet FDA efficacy and safety standards. HairClean 1–2-3 Some products are available that claim to loosen (Quantum Health, Eugene, OR; anise, ylang ylang, the “glue” that attaches nits to the hair shaft, thus coconut oils, and isopropyl alcohol) was found to be making the process of “nit picking” easier. Vinegar at least as effective as the permethrin product Nix by or vinegar-based products (Clear Lice Egg Remover Gel [Care Technologies, Darien, CT]) are intended tobe applied to the hair for 3 minutes before combing Occlusive Agents
out the nits. No clinical benefit has been demonstrat- A “petrolatum shampoo” consisting of 30 to 40 g ed.1,33 Eight percent formic acid (Step 2 [Genderm, of standard petroleum jelly massaged on the entire Lincolnshire, IL]) is applied to wet hair for 10 min- surface of the hair and scalp and left on overnight utes before combing out the nits and has been shown with a shower cap has been suggested. Diligent to have some benefit in one study.40 Neither of these shampooing is usually necessary for at least the next products has been tested with or are recommended 7 to 10 days to remove the residue. It is postulated for use with permethrin because they may interfere with that product’s residual activity. A variety of SCHOOL CONTROL MEASURES
other products, from acetone and bleach to vodka Screening
and WD-40 (WD-40 Company, San Diego, CA), have Screening for nits alone is not an accurate way of proved to be ineffective in loosening nits from the predicting which children will become infested, and hair shaft33 and present an unacceptable risk to the screening for live lice has not been proven to have a significant effect on the incidence of head lice in aschool community over time.2,15 In addition, such Pediculicide Resistance
screening has not been shown to be cost-effective. In No currently available pediculicides are 100% ov- a prospective study of 1729 school children screened icidal, and resistance has been reported with lindane, for head lice, only 31% of the 91 children with nits pyrethrins, and permethrin.20 This is not unantici- had concomitant lice. Only 18% of those with nits pated, because insects have been known to develop alone converted to an active infestation over 14 days resistance to products over time. The actual preva- of observation.41 Although those children having lence of resistance is not known. It is very important greater than or equal to 5 nits within 1 cm of the scalp that health care professionals continue to recom- were significantly more likely to develop an infesta- mend safe and clinically tested products. When faced tion than those with fewer nits (32% vs 7%), still only with a persistent case of head lice, health care pro- 1/3 of these higher-risk children converted. Further- fessionals must consider several possible explana- more, school exclusion of children with nits alone would have resulted in many children missingschool unnecessarily in this study population. Sev- • Misdiagnosis (no active infestation or misidentifi- eral descriptive studies suggest that education of parents in diagnosing and managing head lice may • Noncompliance (not following treatment proto- be helpful.42–44 Because of the lack of evidence of efficacy, classroom or school-wide screening should • Reinfestation (lice acquired after treatment); • Lack of ovicidal or residual killing properties of It would be prudent to periodically provide infor- mation to families of all children on the diagnosis, • Resistance of lice to the pediculicide.
treatment, and prevention of head lice. Parents Even when resistance is suspected, it may be pru- should be encouraged to check their children’s heads dent to continue to use a permethrin or pyrethrin for lice if the child is symptomatic; school screenings product rather than resort to less safe and/or more do not take the place of these more careful toxic products. However, select cases may warrant checks.5,44–46 It may be helpful for the school nurse or other trained persons to check a student’s head ifhe or she is demonstrating symptoms.
ENVIRONMENTAL INTERVENTIONS
Management on the Day of Diagnosis
If an index case is identified, all household mem- Because a child with an active head lice infestation bers should be checked for head lice, and only those has likely had the infestation for a month or more by with live lice or nits within 1 cm of the scalp should the time it is discovered, poses little risk to others, be treated. It is prudent to treat family members who and does not have a resulting health problem, he or share a bed with the person with infestation, even if she should remain in class but be discouraged from no live lice are found. Fomite transmission is less close direct head contact with others. If a child is likely than transmission by head-to-head contact1; assessed as having head lice, confidentiality must be however, it is prudent to clean hair care items and maintained so the child is not embarrassed. The bedding of the individual with infestation. Only child’s parent or guardian should be notified that other items, clothing, furniture, or carpeting that day by telephone or a note sent home with the child have been in contact with the head of the person with at the end of the school day stating that prompt, infestation in the 24 to 48 hours before treatment proper treatment of this condition is in the best in- should be considered for cleaning, given the fact that terest of the child and his or her classmates. Common louse survival off the scalp beyond 48 hours is ex- sense should prevail when deciding how “conta- tremely unlikely. Washing, soaking, or drying items gious” an individual child may be (a child with at temperatures greater than 130°F will kill stray lice hundreds versus a child with 2 live lice). It may be or nits. Furniture, carpeting, car seats, and other prudent to check other children who were most fabrics or fabric-covered items can be vacuumed.
likely to have had direct head-to-head contact with Pediculicide spray should not be used, because ex- the index child. In an elementary school, often the posure cannot be controlled. Nits are unlikely to most efficient way to deal with the problem is to incubate and hatch at room temperatures; if they did, notify the parents or guardians of all children in the the nymphs would need to find a source of blood for index child’s classroom, encouraging that all chil- feeding within hours of hatching. Although it is dren be checked at home and treated if appropriate rarely necessary, items that cannot be washed can be before returning to school the next day.
bagged in plastic for 2 weeks, by which time any nitsthat may have survived would have hatched, and Criteria for Return to School
nymphs would die without a source for feeding.
A child should be allowed to return to school after Herculean cleaning measures are not beneficial.
proper treatment. Some schools have had “no nit” policies under which a child was not allowed 3. Permethrin 1% (Nix) is currently the recom- to return to school until all nits were removed.
mended treatment for head lice, with retreatment The American Academy of Pediatrics and the Na- in 7 to 10 days if live lice are seen. Instructions on tional Association of School Nurses (www.nasn.org/ proper use of products should be carefully re- positions/nitfree.htm) discourage such policies.
layed. Safety and efficacy should be taken into However, nit removal at the time of treatment by the account when recommending any product for parent or guardian may be considered for the follow- 4. None of the currently available pediculicides are • Nit removal may decrease diagnostic confusion.
100% ovicidal and resistance has been reported • Nit removal may decrease the possibility of un- with lindane, pyrethrins, and permethrin. Treat- ment failure does not equate with resistance, and • Some experts recommend removal of nits within 1 most instances of such failure represent misdiag- cm of the scalp to decrease the small risk of self- nosis/misidentification or noncompliance with 5. Head lice screening programs have not been The school nurse, if present, can perform a valu- proven to have a significant effect on the inci- able service by rechecking a child’s head if requested dence of head lice in the school setting over time to do so by a parent. In addition, the school nurse can and are not cost-effective. Parent education pro- offer extra help to families of children who are re- grams may be helpful in the management of head peatedly or chronically infested. In rare instances, it may be helpful to make home visits or involve public 6. Manual removal of nits after treatment with a health nurses to ensure that treatment is being con- pediculicide is not necessary to prevent spread. In ducted effectively. No child should be allowed to the school setting, removal may be considered to miss valuable school time because of head lice. Nu-merous anecdotal reports exist of children missing weeks of school and even being forced to repeat a 7. No healthy child should be excluded from or al- lowed to miss school time because of head lice.
“No nit” policies for return to school should be Reassurance of Parents, Teachers, and Classmates
The school can be most helpful by making avail- able accurate information on diagnosis, treatment, and prevention of head lice to the entire school com- munity in an understandable form. Information sheets in different languages and visual aids for fam- ilies with limited language skills should be devel- oped by schools and/or local health departments. If pediatricians and schools take the lead in reacting in a calm manner, parents will be able to focus on appropriate treatment without getting unduly upset.
Child Care and “Sleep Over” Camps
National Education Association, Health Information Little information is available on the incidence and control of head lice outside of the school-aged pop- Centers for Disease Control and Prevention ulation and outside of school. Because head lice are most readily transmitted by direct head-to-head con- tact, child care centers and camps where childrenshare sleeping quarters may allow for easier spread.
Therefore, it may be prudent to establish stricter criteria than in the school-based setting for identify- Committee on Infectious Diseases, 2001–2002 ing and treating others in these special settings once Carol J. Baker, MDRobert S. Baltimore, MD SUMMARY OF KEY POINTS
Margaret C. Fisher, MDJulia A. McMillan, MD 1. Pediatricians should be knowledgeable about head lice infestations and treatments and should be available as information resources for families, schools, and other community agencies.
2. School personnel involved in detection of head lice infestation should be appropriately trained.
The importance and difficulty of correctly diag- nosing an active head lice infestation should be acknowledged. Schools should examine any lice related policies they may have with this in mind.
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reaffirmed, revised, or retired at or before that time.

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