Head Lice - American Academy of Pediatrics
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CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care
Head Lice
Cynthia D. Devore, MD, FAAP, Gordon E. Schutze, MD, FAAP, THE COUNCIL ON SCHOOL HEALTH AND COMMITTEE ON
INFECTIOUS DISEASES
Head lice infestation is associated with limited morbidity but causes a high abstract
level of anxiety among parents of school-aged children. Since the 2010 clinical
report on head lice was published by the American Academy of Pediatrics,
newer medications have been approved for the treatment of head lice. 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.
Head lice (Pediculus humanus capitis) have been companions of the human
species since antiquity. Anecdotal reports from the 1990s estimated
annual direct and indirect costs totaling $367 million, including remedies
and other consumer costs, lost wages, and school system expenses. More
recently, treatment costs have been estimated at $1 billion.1 It is important
to note that head lice are not a health hazard or a sign of poor hygiene and This document is copyrighted and is property of the American
Academy of Pediatrics and its Board of Directors. All authors have filed
are not responsible for the spread of any disease. Despite this knowledge, conflict of interest statements with the American Academy of
there is significant stigma resulting from head lice infestations in many Pediatrics. Any conflicts have been resolved through a process
approved by the Board of Directors. The American Academy of
developed countries, resulting in children being ostracized from their Pediatrics has neither solicited nor accepted any commercial
schools, friends, and other social events.2,3 involvement in the development of the content of this publication.
In the past, parents and other non–health care personnel made the Clinical reports from the American Academy of Pediatrics benefit from
expertise and resources of liaisons and internal (AAP) and external
diagnosis of head lice, and the easy availability of safe and effective over- reviewers. However, clinical reports from the American Academy of
the-counter (OTC) pediculicides often removed the physician from the Pediatrics may not reflect the views of the liaisons or the
organizations or government agencies that they represent.
treatment process. However, the potential for misdiagnosis and the
resulting improper use of pediculicides and the emergence of resistance to The guidance in this report does not indicate an exclusive course of
treatment or serve as a standard of medical care. Variations, taking
both available and newer products, many without proof of efficacy or into account individual circumstances, may be appropriate.
safety, call for increased physician involvement in the diagnosis and All clinical reports from the American Academy of Pediatrics
treatment.4,5 Optimal treatments should be safe, should rapidly rid the automatically expire 5 years after publication unless reaffirmed,
revised, or retired at or before that time.
individual of live lice, viable eggs, and residual nits, and should be easy to
use and affordable.6 Additionally, because lice infestation is benign, FINANCIAL DISCLOSURE: The authors have indicated they do not have
a financial relationship relevant to this article to disclose.
treatments should not be associated with adverse effects and should be
reserved for patients on whom living lice are found. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they
have no potential conflicts of interest relevant to this article to
disclose.
www.pediatrics.org/cgi/doi/10.1542/peds.2015-0746
ETIOLOGIC AGENT
DOI: 10.1542/peds.2015-0746
The adult head louse is 2 to 3 mm long (the size of a sesame seed), has
6 legs, and is usually tan to grayish-white in color. The female lives up to 3 to PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
4 weeks and, once mature, can lay up to 10 eggs per day. These tiny eggs Copyright © 2015 by the American Academy of Pediatrics
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PEDIATRICS Volume 135, number 5, May 2015 FROM THE AMERICAN ACADEMY OF PEDIATRICSare firmly attached to the base of influenced by hair length or by nurses, teachers, and parents to
the hair shaft within approximately frequent brushing or shampooing. a laboratory for identification were
4 mm of the scalp with a gluelike found to be artifacts, such as
substance produced by the louse. Viable TRANSMISSION dandruff, hairspray droplets, scabs,
eggs camouflaged with pigment to dirt, or other insects (eg, aphids
match the hair color of the infested Lice do not hop or jump; they can blown by the wind and caught in the
person often are seen more easily at the only crawl, and pets do not play hair).5 In general, eggs found more
posterior hairline. Empty egg casings a role in the transmission of human than 1 cm from the scalp are unlikely
(nits) are easier to see because they lice.9 However, there are reports that to be viable, although some
appear white against darker hair. combing dry hair can build up researchers in warmer climates have
(Note that some experts refer to enough static electricity to physically found viable eggs farther from the
“eggs” as containing the developing eject an adult louse from an infested scalp.8
nymph and use “nits” to refer to scalp for a distance of 1 m.10 In most
empty egg casings; others use the cases, transmission occurs by
term “nits” to refer to both eggs and direct contact.9,11 Indirect spread PREVENTION
the empty casings). The eggs are through contact with personal
It is unlikely that all head lice
incubated by body heat and typically belongings of an infested individual
infestations can be prevented,
hatch in 8 to 9 days, but hatching (combs, brushes, hats) is much less
because young children come into
can vary from 7 to 12 days depending likely to occur.12 Lice found on combs
head-to-head contact with each other
on whether the ambient climate is hot are likely to be injured or dead,13
frequently. It is prudent for children
or cold. Once it hatches, a nymph and a louse is not likely to leave
to be taught not to share personal
leaves the shell casing and passes a healthy head unless there is a heavy
items, such as combs, brushes, and
through a total of 3 nymph stages infestation.14 In 1 study, live lice were
hats, but one should not refuse to
(instars) during the next 9 to 12 days found on only 4% of pillowcases
wear protective headgear because of
before reaching the adult stage. The used by infested volunteers.15 Thus,
fear of head lice. In environments
female louse can mate and begin to the major focus of control activities
where children are together, infested
lay viable eggs approximately should be to reduce the number of
children should be treated promptly
1.5 days after becoming an adult. If lice on the head and to lessen the
to minimize spread to others. Regular
not treated, the cycle repeats itself risks of head-to-head contact.
surveillance by parents is one way to
approximately every 3 weeks.7 detect and treat early infestations,
The louse feeds by injecting small DIAGNOSIS thereby preventing the spread to
amounts of saliva, which has Identification of eggs (nits), nymphs, others.
vasodilatory and anticoagulation or adult lice with the naked eye
properties, into the scalp, allowing establishes the diagnosis. This can be
the louse to suck tiny amounts of difficult sometimes because lice TREATMENT
blood every few hours. Pruritus avoid light and can crawl quickly. Never initiate treatment unless there
results from sensitization to Studies have revealed that diagnosis is a clear diagnosis with living lice.
components of the saliva. With a first of infestation by using a louse comb The ideal treatment of lice should be
case of head lice, pruritus may not is quicker and more efficient.16 safe, free of toxic chemicals, readily
develop for 4 to 6 weeks, because it Some experts have suggested using available without a prescription, easy
takes that amount of time for a lubricant (water, oil, or to use, effective, and inexpensive.
sensitivity to result. conditioner) to “slow down” the Local patterns of resistance (if
movement of lice and eliminate the known), ease of use, and cost
Head lice usually survive for less than
possibility of static electricity.17 Tiny (Table 1) also are considerations
1 day away from the scalp, and their
eggs may be easier to spot at the when choosing a treatment choice.
eggs cannot hatch at temperatures
nape of the neck or behind the ears, Published reviews of available
lower than those near the scalp.8
within 1 cm of the scalp. It is efficacy studies and comparative
important not to confuse eggs or trials of pediculicides have used
EPIDEMIOLOGY nits, which are firmly affixed to the different inclusion criteria and
In the United States, reliable data on hair shaft, with dandruff, hair casts, reached different conclusions.18–20 A
prevalence of head lice are not or other hair debris, which are not. It Cochrane review concerning
available.9 All socioeconomic groups is also important not to confuse live pediculicides has a substantial update
are affected, and infestations are seen eggs with dead or empty egg cases under way, because previous reviews
throughout the world. Head lice (nits). Many presumed “lice” and were conducted before the
infestation is not significantly “nits” submitted by physicians, development of drug resistances.21
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e1356 FROM THE AMERICAN ACADEMY OF PEDIATRICSTABLE 1 Topical Pediculicides for the Treatment of Head Lice in the United States after rinsing. In addition, none of
Product Availability Cost Estimate these natural pyrethrins are totally
Permethrin 1% lotion (Nix) OTC $
ovicidal (newly laid eggs do not have
Pyrethrins + piperonyl butoxide (Rid) OTC $ a nervous system for several days);
Malathion 0.5% (Ovide) Prescription $$$$ 20% to 30% of eggs remain viable
Benzyl alcohol 5% (Ulesfia)a Prescription $$-$$$$ after treatment,24 which necessitates
Spinosad 0.9% suspension (Natroba) Prescription $$$$ a second treatment to kill newly
Ivermectin 0.5% lotion (Sklice) Prescription $$$$
emerged nymphs hatched from eggs
Adapted from refs 18, 40.
$, ,$25; $$, $26–$99; $$$, $100–$199; $$$$, $200–$299.
that survived the first treatment.
a Cost varies based on the length of the hair and the number of bottles of medication required. Suggested retreatment with these
products is similar to permethrin
The guidance in this report is eggs not killed with the first (1%) described previously.26
intended for use by pediatricians and application.24 However, conditioners Although pyrethrins were extremely
other practitioners in the United and silicone-based additives present effective when introduced in the mid-
States. The Canadian Pediatric Society in almost all currently available 1980s, recent study results have
recently updated its position shampoos impair permethrin indicated that efficacy has decreased
statement on head lice infestation.22 adherence to the hair shaft and substantially because of development
Pediatricians who work in other reduce its residual effect.6 Although of resistance.4 The prevalence of
countries, especially developing many repeat the application resistance has not been
countries in which head lice are naive sometime between day 7 to 10 after systematically studied but seems to
to pediculicides, should use treatment if live lice are seen, new be highly variable from community to
products or methods that are most evidence based on the life cycle of lice community and country to country.
economical, effective, and safe. The suggests that retreatment at day 9 is
following products and methods can optimal.6,25 An alternate treatment Malathion (0.5%)
be effective for treating head lice. schedule on days 0, 7, and 13 to 15 The organophosphate (cholinesterase
has been proposed on the basis of the inhibitor) 0.5% malathion (Ovide;
Pediculicides longest possible life cycle of lice for Taro Pharmaceutical Industries,
Permethrin (1%) this and other nonovicidal agents Hawthorne, NY) was reintroduced for
Permethrin has been the most (eg, pyrethrins plus piperonyl the treatment of head lice in the
studied pediculicide in the United butoxide).26 Resistance to 1% United States in 1999 after being
States and is the least toxic to permethrin has been reported,6,27–30 taken off the market twice because of
humans.18 Introduced in 1986 as but its prevalence is unknown. problems related to prolonged
a prescription-only treatment, 1% application time, flammability, and
permethrin lotion was approved for Pyrethrins Plus Piperonyl Butoxide odor. It is available only by
OTC use in 1990 and is marketed as Manufactured from natural extracts prescription as a lotion that is applied
a “creme rinse” (Nix; Insight from the chrysanthemum, pyrethrins to dry hair, left to air dry, then washed
Pharmaceuticals, Trevose, PA). One are formulated with piperonyl off after 8 to 12 hours, although
percent permethrin lotion is one of butoxide (eg, RID; Bayer HealthCare some study results have suggested
the drugs available to treat head LLC, Whippany, NJ) and are available effectiveness when left on for as short
lice.23 Permethrin is a synthetic OTC. Pyrethrins are neurotoxic to lice a time as 20 minutes.32 Head lice in
pyrethroid with extremely low but have extremely low mammalian the United Kingdom and elsewhere
mammalian toxicity. Reported toxicity. Pyrethrins should be avoided have shown resistance to malathion
adverse effects include pruritus, in people who are allergic to preparations, which have been
erythema, and edema. Permethrin is chrysanthemums. The labels warn available for decades in those
less allergenic than pyrethrins and against possible allergic reaction in countries.33,34 The current US
does not cause allergic reactions in patients who are sensitive to formulation of malathion (Ovide
individuals with plant allergies. The ragweed, but modern extraction lotion, 0.5%) differs from the
product is applied to damp hair that techniques minimize the chance of malathion products available in
is first shampooed with product contamination, and reports Europe in that it contains terpineol,
a nonconditioning shampoo and then of true allergic reactions have been dipentene, and pine needle oil, which
towel dried. It is left on for 10 rare.31 These products are available themselves have pediculicidal
minutes and then rinsed off. in shampoo or mousse formulations properties and may delay
Permethrin leaves a residue on the that are applied to dry hair and left on development of resistance. Malathion
hair that is designed to kill nymphs for 10 minutes before rinsing out. has high ovicidal activity,24 and
emerging from the 20% to 30% of No residual pediculicidal activity remains a single application is adequate for
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PEDIATRICS Volume 135, number 5, May 2015 e1357most patients. When compared with should be applied topically for a lotion form by the FDA in 2012 for
pyrethrins and permethrin, malathion 10 minutes and repeated as stated children 6 months or older for head
was the most pediculicidal and previously for permethrin 1%. Benzyl lice. This medication increases the
ovicidal agent with highest cure rates alcohol is available by prescription chloride ion permeability of muscle
after 1 application.6,32 However, the and should not be used in neonates, cells, resulting in hyperpolarization,
product should be reapplied in 7 to because it has been associated with paralysis, and death of the lice.41
9 days if live lice are still seen. The high the neonatal gasping syndrome.36 Combined data from 2 multisite,
alcohol content of the product (78% randomized, double-blinded studies
isopropyl alcohol) makes it highly Spinosad (0.9% Suspension) comparing a single application of
flammable; therefore, patients and Spinosad (Natroba; ParaPRO LLC, 0.5% ivermectin lotion with a vehicle
their parents should be instructed to Carmel, IN) was approved by the FDA control found that significantly more
allow the hair to dry naturally; not to for topical use in children 6 months patients receiving ivermectin were
use a hair dryer, curling iron, or flat of age and older. It is contraindicated louse free on day 2 as compared with
iron while the hair is wet; and not to for children younger than 6 months the control (94.9% vs 31.1%), day 8
smoke near a child receiving because it also contains benzyl (85.2% vs 20.8%), and day 15
treatment. Safety and effectiveness of alcohol. The compounds, spinosyn A (73.8% vs 17.6%; P , .001 for each
malathion lotion have not been and spinosyn D, are derived through comparison).41 Topical ivermectin
established in children younger than natural fermentation from soil lotion is available by prescription, is
6 years, and the product is bacterium, Saccharopolyspora applied to dry hair and scalp, and is
contraindicated in children younger spinosa. They are suspended in rinsed after 10 minutes. Only 1
than 24 months. Because malathion is a natural ratio of 5:1 and together are application is required, because
a cholinesterase inhibitor, there is known by the generic term spinosad. when the treated eggs hatch, the lice
a theoretical risk of respiratory Spinosad has a broad spectrum of are not able to feed as a result of
depression if accidentally ingested, activity against insects, including pharyngeal muscle paralysis and,
although no such cases have been many species of lice. Activity appears therefore, are not viable.42 Adverse
reported. to be both ovicidal and pediculicidal effects are rare and include skin or
by disrupting neuronal activity and eye irritation and erythema, burning,
Benzyl Alcohol 5% lingering long enough to exert its or dryness.41
Benzyl alcohol 5% (Ulesfia; Concordia effect on the developing larvae until
they form an intact nervous
Lindane (1%)
Pharmaceuticals, Inc, Bridgetown,
Barbados) was approved by the US system.37 Superiority of spinosad Lindane is no longer recommended
Food and Drug Administration (FDA) over permethrin has been by the American Academy of
in April 2009 for treatment of head demonstrated with treatment success Pediatrics or the Medical Letter for
lice in children older than 6 months. rates of 84% to 87% as compared use as treatment of pediculosis
The product is not neurotoxic to the with 43% to 45%.38 Adverse capitis.
lice, but kills them by asphyxiation. reactions described include
application site erythema (3%), Removal of Topical Pediculicides
Phase III trials of this agent have
included 2 randomized, multicenter, ocular erythema (2%), and All topical pediculicides should be
double-blind, vehicle-controlled trials application site irritation (1%).38–40 rinsed from the hair over a sink
and 1 open-label study.35 The overall Spinosad is available by prescription rather than in the shower or bath to
end point of these trials was and should be applied to dry hair by limit skin exposure, and with warm
treatment success or no live lice at saturating the scalp and working rather than hot water to minimize
14 days after the final application. outward to the ends of the hair, absorption attributable to
The effectiveness of benzyl alcohol which may require a whole bottle. vasodilation.43
(75.0%–76.2%) was statistically Spinosad should be rinsed
greater as compared with vehicle 10 minutes after application. A second Topical Reactions
placebo (4.8%–26.2%). The most treatment is given at 7 days if live lice Itching or mild burning of the scalp
common adverse reactions after are seen. Safety in children younger caused by inflammation of the skin in
treatment included pruritus (12%), than 4 years has not been response to topical pharmaceutical
erythema (10%), pyoderma (7%), established. agents can persist for many days after
and ocular irritation (6%).17 When lice are killed and is not a reason for
applied, sufficient amounts should be Ivermectin (0.5%) retreatment. Topical corticosteroids
used on dry hair to saturate the scalp Ivermectin (Sklice; Sanofi Pasteur, and oral antihistamines may be
and entire length of the hair. Benzyl Swiftwater, PA), a widely used beneficial for relieving these signs
alcohol is not ovicidal and, therefore, anthelmintic agent, was approved in and symptoms.
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e1358 FROM THE AMERICAN ACADEMY OF PEDIATRICSScabicides Used Off-Label for Lice Sulfamethoxazole-Trimethoprim insecticidal chemicals produce toxic
Permethrin (5%) The oral antibiotic agent effects as well. The safety and efficacy
sulfamethoxazole-trimethoprim of herbal products are currently not
Permethrin 5% is not currently
(Septra [Monarch Pharmaceuticals, regulated by the FDA, and until more
approved by the FDA for use as
Bristol, TN], Bactrim [Mutual data are available, their use in infants
a pediculicide. Five percent and children should be avoided.
permethrin (Elimite; Prestium Pharmaceutical, Philadelphia, PA],
Pharma, Inc, Newton, PA) is available and generic cotrimoxazole) has been
Occlusive Agents
by prescription only as a cream, cited as effective against head lice. It
usually applied overnight for scabies is not currently approved by the FDA Occlusive agents, such as “petrolatum
for infants as young as 2 months. It for use as a pediculicide.52 It is shampoo,” mayonnaise, butter or
has been used for the treatment of postulated that this antibiotic agent margarine, herbal oils, and olive oil,
head lice that seem to be recalcitrant kills the symbiotic bacteria in the gut applied to suffocate the lice are
to other treatments.44 The results of 1 of the louse or perhaps has a direct widely used but have not been
study suggested that lice resistant to toxic effect on the louse. The results evaluated for effectiveness in
1% permethrin will not succumb to of 1 study indicated increased randomized controlled trials. To date,
higher concentrations.29 effectiveness when sulfamethoxazole- only anecdotal information is
trimethoprim was given in available concerning effectiveness.
Crotamiton (10%) combination with permethrin 1% An uncontrolled, nonrandomized
when compared with permethrin 1% 2004 study reported a 96% “cure”
Crotamiton is not currently approved by
or sulfamethoxazole-trimethoprim rate with Cetaphil cleanser (Galderma
the FDA for use as a pediculicide. This
alone; however, the treatment groups Laboratories, Fort Worth, TX) applied
product is available by prescription only
were small.53 Rare severe allergic to the hair, dried on with a
as a lotion (Eurax; Ranbaxy, Jacksonville,
reactions (Stevens-Johnson handheld hair dryer, left on overnight,
FL), usually used to treat scabies. One
syndrome) to this medication make it and washed out the next morning and
study showed it to be effective against
a potentially undesirable therapy if repeated once per week for 3 weeks.
head lice when applied to the scalp and
alternative treatments exist.7 Instructions for its use are available
left on for 24 hours before rinsing out.45
Other reports have suggested that 2 on the Internet.57 It has not been
consecutive nighttime applications
ALTERNATIVE APPROACHES approved by the FDA for use as
safely eradicate lice from adults.46 Safety a pediculicide. Dimethicone lotion
“Natural” Products
and absorption in children, adults, and (4% long-chain linear silicone in
Essential oils have been widely used a volatile silicone base) in two 8-hour
pregnant women have not been
in traditional medicine for the treatments 1 week apart eradicated
evaluated.
eradication of head lice, but because head lice in 69% of participants in the
of the variability of their constitution, United Kingdom.58 In the United
Oral Agents Used Off-Label for Lice
the effects may not be reproducible.54 States, the OTC product LiceMD
Ivermectin In addition, these oils (eg, ylang ylang (Reckitt-Benckiser, Slough, England)
This product (Stromectol; Merck & oil) may be a source of contact contains dimethicone, an emollient.
Co, Whitehouse Station, NJ) is an sensitization, which limits their use. Isopropyl myristate 50% (Resultz;
anthelmintic agent structurally Several products have been studied Nycomed Canada, Inc, Oakville,
similar to macrolide antibiotic agents, (eg, Andiroba oil, Quassia vinegar, Ontario, Canada), a hair rinse that
but without antibacterial activity. A melaleuca oil [tea tree oil], lavender dissolves the waxy exoskeleton of the
single oral dose of 200 mg/kg, oil).55,56 As natural products, they louse, which leads to dehydration and
repeated in 10 days, has been shown are not required to meet FDA efficacy death of the louse, has recently
to be effective against head lice.47,48 and safety standards for become available in Canada.59,60
Most recently, a single oral dose of pharmaceuticals. HairClean 1-2-3
Close surveillance of patients treated
400 mg/kg, repeated in 7 days, has (Quantum Health, Eugene, OR [anise,
with non–FDA-approved products
been shown to be more effective than ylang-ylang, coconut oils, and
may improve discovery of treatment
0.5% malathion lotion.49 Ivermectin isopropyl alcohol]) was found to be at
failure early, so other evidence-based
may cross the blood/brain barrier least as effective as the permethrin
and FDA treatments might be
and block essential neural product Nix by 1 investigator.2
implemented.
transmission; young children may be Although many plants naturally
at higher risk of this adverse drug produce insecticides for their own
reaction. Therefore, oral ivermectin protection that may be synthesized Desiccation
should not be used for children who for use by humans, such as The AirAllé (Larada Sciences, Salt
weigh less than 15 kg.50,51 pyrethroids, some of these Lake City, UT) device is a custom-built
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PEDIATRICS Volume 135, number 5, May 2015 e1359machine that uses one 30-minute process easier.63–66 Nit-removal New Products
application of hot air in an attempt to combs are sold commercially. As new products are introduced, it is
desiccate the lice. One study showed However, it appears that type of important to consider effectiveness,
that subjects had nearly 100% comb used is less important than safety, expense, availability, patient
mortality of eggs and 80% mortality that combing occurs after treatment, preference, and ease of application.
of hatched lice.61 The machine is which may be most easily Assessment of the severity of the
expensive, and the operator requires accomplished on wet hair. Studies infestation, the number of
special training in its use. A regular have suggested that lice removed by recurrences, the local levels of
blow dryer should not be used in an combing and brushing are damaged resistance to available pediculicides,
attempt to accomplish this result, and rarely survive.11 exclusion of children from school, and
because investigators have shown the potential for transmission also are
There are battery-powered
that wind and blow dryers can cause
“electronic” louse combs with important when deciding about the
live lice to become airborne and, thus, use of newer products.
oscillating teeth (MagiComb;
potentially spread to others in the
Quantum Health, Eugene, OR) that
vicinity. Pediculicide Resistance
claim to remove live lice and nits as
well as combs that resemble small No currently available pediculicide is
Other Agents
“bug zappers” (Robi-Comb; LiceGuard 100% ovicidal, and resistance to
Highly flammable substances, such as LLC, Needham, MA) that claim to kill pyrethrins, permethrin, and the
gasoline or kerosene, or products live lice.67 No randomized, case- United Kingdom formulation of
intended for animal use, are never controlled studies have been malathion has been
appropriate in treatment of head lice performed with either type of comb. reported.33,34,70–75 This resistance is
in humans. Their instructions warn not to use on not unanticipated, because insects
people with a seizure disorder or develop resistance to products over
Manual Removal time. The actual prevalence of
a pacemaker.
Although there is little peer- resistance to particular products is
Some products are available that
reviewed information in the not known and can be regional. It is
claim to loosen the “glue” that
literature about the benefits of the important that health care
attaches nits to the hair shaft, thus
manual removal of live lice and nits, professionals choose safe and
making the process of “nit-picking”
the inherent safety of the manual effective products. When faced with
easier. Vinegar or vinegar-based
removal relative to the minor toxicity a persistent case of head lice after
products are intended to be applied
of the pesticides is real and can be using a pharmaceutical pediculicide,
to the hair for 3 minutes before
part of an arsenal by pediatricians health care professionals can consider
combing out the nits. No clinical
when determining treatment several possible explanations,
benefit has been demonstrated.7,68
options. There is an obvious benefit including the following:
This product has not been tested
of the manual removal process that • misdiagnosis (no active infestation
with and is not indicated for use
can allow a parent and child to have or misidentification);
with permethrin, because it may
some close, extended time together
while safely removing infestations
interfere with permethrin’s residual • lack of adherence (patient unable
activity. A variety of other products, or unwilling to follow treatment
and residual debris without using
from acetone and bleach to vodka protocol);
potentially toxic chemicals on the
and WD-40 (WD-40 Company, San • inadequate treatment (not using
child or in the environment.
Diego, CA), have proved to be sufficient product to saturate hair;
Furthermore, manual removal of nits
ineffective in loosening nits from failing to follow directions);
will help to diminish the social
the hair shaft68 and present an
stigma and isolation a child can have • reinfestation (lice reacquired after
unacceptable risk to the patient. It
in the school setting. Individuals also treatment);
seems that nature has protected the
may want to remove nits for • lack of ovicidal or residual killing
louse by making the nit sheath similar
aesthetic reasons or to decrease properties of the product (eggs not
in composition to the hair, so that
diagnostic confusion. Because none killed can hatch and cause self-
agents designed to unravel the nit
of the pediculicides are 100% reinfestation); and/or
sheath can also damage human hair.69
ovicidal, nits (especially the ones
within 1 cm of the scalp) should be Although effective for removing lice • resistance of lice to the
removed manually after treatment and eggs, shaving the head generally pediculicide.
with any product. Nit removal can be is not required, nor recommended, If resistance is proven, and an active
difficult and tedious.62 Fine-toothed because it can be traumatizing to infestation is documented, benzyl
“nit combs” are available to make the a child and distressing to the parent. alcohol 5% can be prescribed if the
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e1360 FROM THE AMERICAN ACADEMY OF PEDIATRICSpatient is older than 6 months, or head lice after 30 minutes of diagnosing and managing head lice
malathion 0.5% can be prescribed if swimming.76 Pediculicide spray is not may be helpful.80–83 Parents can be
the patient is older than 24 months if necessary and should not be used. encouraged to check their children’s
safe use by responsible parents Viable nits are unlikely to incubate heads for lice regularly and if the
seems reasonable. For younger and hatch at room temperatures; if child is symptomatic. School
patients, or if the parent cannot afford they did, the nymphs would need to screenings do not take the place of
or does not wish to use a pediculicide, find a source of blood for feeding these more careful parental
manual removal via wet combing or within hours of hatching. Although it checks.13,84–86 It may be helpful for
an occlusive method can be used, is rarely necessary, items that cannot the school nurse or other trained
with emphasis on careful technique be washed can be bagged in plastic person to check a specific student’s
and the use of 2 to 4 properly timed for 2 weeks, a time when any nits that head if he or she is demonstrating
treatment cycles. may have survived would have symptoms.
hatched and nymphs would die
ENVIRONMENTAL INTERVENTIONS without a source for feeding. Management on the Day of Diagnosis
If a person is identified with head lice, Exhaustive cleaning measures are not Because a child with an active head
all household members should be beneficial. lice infestation likely has had the
checked for head lice, and those with infestation for 1 month or more by
live lice or nits within 1 cm of the CONTROL MEASURES IN SCHOOLS the time it is discovered and poses
scalp should be treated. In addition, it Screening little risk to others from the
is prudent to treat family members infestation, he or she should remain
who share a bed with the person with Screening for nits alone is not an in class, but be discouraged from
infestation, even if no live lice are accurate way of predicting which close direct head contact with others.
found. Fomite transmission is less children are or will become infested, If head lice is diagnosed in a child,
likely than transmission by head-to- and screening for live lice has not confidentiality is important. The
head contact7; however, it is prudent been proven to have a significant child’s parent or guardian may be
to clean hair care items and bedding effect on the incidence of head lice in notified that day by telephone or by
used by the individual with a school community over time.8,19,77 having a note sent home with the
infestation. One study revealed that In addition, such screening has not child at the end of the school day
head lice can transfer to pillowcases been shown to be cost-effective. In stating that prompt, proper treatment
at night, but the incidence is low a prospective study of 1729 of this condition is in the best interest
(4%). Changing just the pillowcase schoolchildren screened for head lice, of the child and his or her classmates.
could minimize this risk of head lice only 31% of the 91 children with nits Common sense and calm should
transmission.15 Only items that have had concomitant live lice. Only 18% prevail within a school when deciding
been in contact with the head of of those with nits alone converted to how “contagious” an individual child
the person with infestation in the 24 to having an active infestation during may be (a child with hundreds versus
48 hours before treatment should be 14 days of observation.78 Because of a child with 2 live lice). It may be
considered for cleaning, given the fact the lack of evidence of efficacy, prudent to check other children who
that louse survival off the scalp routine classroom or schoolwide are symptomatic or who were most
beyond 48 hours is extremely screening should be discouraged. likely to have had direct head-to-head
unlikely. Such items may include Although children with at least 5 nits contact with the infested child. Some
clothing, headgear, furniture, within 1 cm of the scalp were experts argue that because of the
carpeting, and rugs. Washing, significantly more likely to develop an relatively high prevalence of head lice
soaking, or drying items at infestation than were those with in young school-aged children, it may
temperatures greater than 130°F will fewer nits (32% vs 7%), only one- make more sense to alert parents
kill stray lice or nits. Furniture, third of the children at higher risk only if a high percentage of children
carpeting, car seats, and other fabrics converted to having an active in a classroom are infested. Other
or fabric-covered items can be infestation. School exclusion of experts feel strongly that these “alert
vacuumed. Although head lice are children with nits alone would have letters” violate privacy laws, cause
able to survive for prolonged periods resulted in many of these children unnecessary public alarm, and
in chlorinated water, it is unlikely that missing school unnecessarily. In reinforce the notion that a head lice
there is a significant risk of addition, head lice infestations have infestation indicates a failure on the
transmission in swimming pools. One been shown to have low contagion in school’s part rather than
study revealed that submerged head classrooms.79 The results of several a community problem.85 However,
lice became immobile and remained descriptive studies have suggested studies examining the efficacy of alert
in place on 4 people infested with that education of parents in letters are not available;
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PEDIATRICS Volume 135, number 5, May 2015 e1361consequently, some schools choose to SUMMARY OF KEY POINTS 6. Benzyl alcohol 5% can be used for
design guidelines that they believe 1. No healthy child should be ex- children older than 6 months, or
best meet the needs of their student cluded from school or allowed to malathion 0.5% can be used for
population, understanding that miss school time because of head children 2 years or older in areas
although a head lice infestation may lice or nits. Pediatricians may ed- where resistance to permethrin
not pose a public health risk, it ucate school communities that or pyrethrins has been demon-
may create a public relations dilemma no-nit policies for return to school strated or for a patient with
for a school. should be abandoned. a documented infestation that has
failed to respond to appropriately
Criteria for Return to School 2. It is useful for pediatricians to be
administered therapy with
knowledgeable about head lice
A child should not be restricted from permethrin or pyrethrins. Spinosad
infestations and treatments
school attendance because of lice, and topical ivermectin are newer
(pediculicide and alternative ther-
because head lice have low contagion preparations that might prove
apies); they may take an active
within classrooms.79 “No-nit” helpful in difficult cases, but the
role as information resources for cost of these preparations should
policies that exclude children until
families, schools, and other com- be taken into account by the pre-
all nits are removed may violate
munity agencies. scriber (Table 1).
a child’s civil liberties and are best
addressed with legal counsel for 3. Unless resistance to these prod-
7. New products should be evaluated
schools. However, most health care ucts has been proven in the com- for safety and effectiveness.
professionals who care for children munity, 1% permethrin or
pyrethrins are a reasonable first 8. School personnel involved in de-
agree that no-nit policies should
choice for primary treatment of tection of head lice infestation
be abandoned.85 International
active infestations if pediculicide should be appropriately trained.
guidelines established in 2007 for
therapy is required. The importance and difficulty of
the effective control of head lice
correctly diagnosing an active
infestations stated that no-nit 4. Carefully communicated instruc- head lice infestation should be
policies are unjust and should be tions on the proper use of prod- emphasized.
discontinued, because they are based ucts are important. Because
on misinformation rather than current products are not com- 9. Head lice screening programs have
objective science.86 The American pletely ovicidal, applying the not been proven to have a signifi-
Academy of Pediatrics and the product at least twice, at proper cant effect over time on the in-
National Association of School intervals, is indicated if permeth- cidence of head lice in the school
Nurses87 discourage no-nit policies rin or pyrethrin products are used setting and are not cost-effective.
that exclude children from school. or if live lice are seen after pre- Parent education programs may be
However, nit removal may decrease scription therapy per manu- helpful in the management of head
diagnostic confusion, decrease the facturer’s guidelines. Manual lice in the school setting.
possibility of unnecessary removal of nits immediately after LEAD AUTHORS
retreatment, and help to decrease treatment with a pediculicide is Cynthia DiLaura Devore, MD, FAAP
the small risk of self-reinfestation not necessary to prevent spread. Gordon E. Schutze, MD, FAAP
and social stigmatization. In the school setting, nit removal
COUNCIL ON SCHOOL HEALTH EXECUTIVE
A school nurse familiar with lice may be considered to decrease
COMMITTEE, 2014–2015
infestations, if present, can perform diagnostic confusion and social
stigmatization. Jeffrey Okamoto, MD, FAAP, Chairperson
a valuable service by rechecking Mandy Allison, MD, MSPH, MEd, FAAP
a child’s head if requested to do so 5. If resistance to available OTC Richard Ancona, MD, FAAP
by a parent. In addition, the school products has been proven in the Elliott Attisha, DO, FAAP
nurse can offer extra help to families community, if the patient is too Cheryl De Pinto, MD, MPH, FAAP
Breena Holmes, MD, FAAP
of children who are repeatedly or young, or if parents do not wish to
Chris Kjolhede, MD, MPH, FAAP
chronically infested. In rare use a pediculicide, consider the Marc Lerner, MD, FAAP
instances, it may be helpful to make manual removal of lice/nits by Mark Minier, MD, FAAP
home visits or involve public health methods such as “wet-combing” or Adrienne Weiss-Harrison, MD, FAAP
nurses if there is concern about an occlusive method (such as pe- Thomas Young, MD, FAAP
whether treatment is being troleum jelly or Cetaphil cleanser), LIAISONS
conducted effectively. Parent with emphasis on careful tech-
Beth Mattey, MS, RN, NCSN – National Association of
education by school health nique, close surveillance, and re- School Nurses
professionals can reinforce similar peating for at least 3 weekly Mary Vernon-Smiley, MD, MPH, MDiv – Centers for
goals for the medical home. cycles. Disease Control and Prevention
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