HEAD LICE MANAGEMENT IN HEAD LICE MANAGEMENT IN SCHOOL SETTINGSSCHOOL SETTINGS
Shirley Gordon, PhD, RNChristine E. Lynn College of Nursing
Florida Atlantic University
February 7, 2009FASN Conference
©
Shirley Gordon, 2009
The Head louse is an Ancient Parasite That:
Needs to feed on human blood every 2-3 hours [1mg per feeding]
Is easily transmitted through head to head contact
Is present on 1% to 3% of the worlds general population at any given time (Roberts, 2002)
Primary weapons used against the parasite areneuro toxic pesticidesLeading pesticide –originally developed as an agent for bio chemical warfare
Costs
Direct: $90 million each year in the US–
Cost of treatment products -
–
Average 5 self treatments before seeking help
Indirect Costs
Indirect:–
Lost school days = lost school funding
•
California –
10% children with lice/4 days =
$3.2 million •
NY -
$20-$40/day/child = $25-$35 million•
Nationwide $10-$40 per day per child/ 33.5 Million children in grades K-8 = $280 - $325 million in lost funding
–
Lost work days $2,720/wages per family per active infestation
Now Imagine:
Your child has head liceYour entire family has head liceAnd despite repeated treatment attempts [sometimes over a period of years] you can’t get rid of it…
Objectives:
Review current research related to head liceIdentify family centered lice treatment and prevention strategies Increase ability to recognize lice, eggs and nits
Head Lice (Pediculosis Capitis)Common among children ages 2 to 12 years old
Widespread throughout the United States and the world
6-12 million cases a year in the US (CDC)
Elementary schools may reach 25% infestation. (Roberts, 2002)
Photo: © 2001-03, Johns Hopkins University School of Medicine: Dermatlas
Head Lice:Head Lice:
Size of sesame seed (adult)Wingless - Do not jump or flyAre human parasites – host specificDo not live more than 24 hrs off their human host. Do not infest homes/schoolsAre highly stigmatized
Life Cycle:Life Cycle:Lifespan approximately 30 days
Females lay up to 5-10 nits (eggs) per day (150-400 in a lifespan)
Nits hatch within 7-10 days and release nymphs (immature louse)
Nymphs reach adult reproductive stage in 8 or 9 days
Nits (Eggs)Nits (Eggs)
Nits, tiny teardrop shaped eggsAttached to one side of the hair shaft with water proof, glue-like substanceLaid 1/4 inch from the scalp. (In warmer climates, viable nits can be found as much as 6 inches or more from the scalp)
Active Infestation
Presence of at least one live louse –
or Live lice & viable nits
Screen the entire familyTreat only active cases
Transmission:Transmission:
Direct head to head contactTheoretically, may be shared through fomits such as hats, combs, and towels, etc. (thought to play a minor role in transmission)
Common Symptoms:Common Symptoms:Many children (50%) experience no symptoms.Symptoms take several weeks to developWhen symptoms occur, the most common are:–
Scratching -
Sleeplessness
–
Red, hive-like bumps on the head.–
Rash on back of neck
Head Lice are a Community Head Lice are a Community Problem:Problem:
Only 1 in 10 transmissions occur at school.
Common Outbreak Times:Common Outbreak Times:•
Start of the School Year
•
After Winter Vacation•
After Spring Break
Whenever children are in the community for extended periods of time
Factors Contributing to Absenteeism
Exclusion PoliciesMisdiagnosis of Active Head LiceFailure to Treat / Treatment FailureFatiguePersistent head Lice
Exclusion Policies
No Nit – Live Lice Only – Non Exclusion Florida School nurses reported that the number of days children were excluded from the 2002-2003 school year for head lice ranged from 0 to 100 days (Gordon, 2004)School Districts vary on the number of days children receive an excused absence for lice
Conversion From Nits to Live Lice
In a CDC study:–
1700 Atlanta children screened
–
91 had evidence of nits or lice (5%)–
Only 28% (476) had active infestation
–
50 (10.5%) children diagnosed with nits (no live lice present) were followed for 2 weeks
–
18% (9) went on to develop live lice–
5 or more nits close to the scalp –
predictor
of
conversion to live lice»
Williams, Reichert , McKenzie, Hightower, & Blake, 2001
Misdiagnosis of Active Infestation
Active Infestation: Live lice & viable nits–
In a research study in which participants were asked to gather samples from identified head lice cases:
•
555 samples were sent in •
57.5% of samples showed evidence of lice & eggs
–
teachers samples / 50% active–
relatives / 47.1% active–
nurses / 31.7% active–
physicians / 11% active»
Pollack,
Kiszewski,
Spielman, (2000)
Failure to Treat / Treatment Failure
Children may be excluded from school because caregivers:–
Fail to treat their child’s head lice
–
Misuse products leading to treatment failure–
Do not complete follow-up
•
Lice and Nit removal–
Experience resistant lice
–
Overuse products–
Do not screen & treat other family members / contacts [contact tracing]
Treatment Approaches: Pesticides
Prescription:LindaneMalathion
OTC:Pyrethroids
Barrier
Dimeticone–
Showing great promise
–
Creates a physical barrier around the louse –
Does not act on the nervous system
Contraindications
On children under 6 months: medical supervisionPreparations with an alcohol base should not be used on children under 5Pyrethroid based products are contraindicated in persons with allergy to chrysanthemum flowersPreparations with an alcohol base should not be used on persons with scalp dermatitis or asthma. –
Well ventilated rooms, away from heat sources like: open flames, stoves, cigarettes, hair dryers
Alternative Treatments
Mechanical removalHerbal and essential oils–
Tea tree oil and lavender oil can be toxic in concentrates
–
Limited empirical evidence to determine effectiveness
Importance of Contact Tracing ( 9 out 10 family members in 4 homes )
Referral case6 yo Female
Uncle 59 Mother/Fatherbrother (10) brother (8)
Aunt (no lice)cousin (4) / cousin (7)
Grandmother 89
FatigueLice are more active at nightChildren with head lice report disrupted sleep patterns resulting in:–
Irritability
–
Diminished ability to concentrate–
Poor school performance
–
Sleepiness in class–
Children sent to health room for falling asleep in class should be checked for head lice
Persistent Head Lice CasesA small number of children develop persistent cases: Diagnosis of live lice 3X in 6 weeks that are not amenable to treatment (Gordon, 2002, 2007)Children with persistent lice may be placed at risk:–
educationally due to excessive absences from school
–
physically from unsafe treatment strategies–
Emotionally from stigma & fear of transmission
Grounded Theory Study of Families Experiencing Persistent Head Lice
Problem–
Caregiver Strain
Process–
Shared Vulnerability
–
Gordon, 2007
Purposive Sample20 parents/caregivers caring for children with persistent head lice–
Mothers (75%)–
Grandmothers (15%)–
Foster father (5%)–
Stepmother (5%)Referral case recruited from–
Public Schools 35%–
Lice treatment facility 60%–
Word of mouth 5%
Age–
22-73 years –
Mean 33 yearsEthic background–
Caucasian 95%–
Hispanic 5%Marital Status–
Single 65%–
Married 35%Participants experiencing financial difficulty obtaining treatment 35%
Children
# Children in the home–
Range 1 to 6
–
Median 3 children50% receiving Free/reduced lunch“Forced absences”from school for lice–
0 to 37 days
–
Mean 11 days
65% Spent time in more than one home30% of children slept in bed with others–
# persons in a bed
•
2 to 4 persons•
Median 3
Problem: Caregiver StrainParents experienced stress from the moment their child was diagnosed with head lice, throughout treatment attempts and long after theinfestation had ended.
Caregiver Strain denotes the enduring nature of the perceived stress of caring for children with persistent head lice.
Stress associated with caring for children with persistent head lice was as persistent as the lice.
“You can’t imagine how stressful this is [lice] – it takes over your whole life!”
Process of Shared Vulnerability ©
Shirley Gordon, 2007
Participants described suffering the same openness to injury as their child with persistent head lice. They were also susceptible to becoming infested with head lice themselves.
Shared Vulnerability
Stage I Being Ostracized
[Conditions]
Stage II Losing Integrity
Of the Self
[Consequences]
Stage III Struggling with
Persistence[Strategies]
Stage IV Managing Strain
[Consequences]
Stage I Being OstracizedDescribes the conditions under which caregiver stain is experienced. Lice myths include:
–
Being unclean–
Living in poverty–
Poor parenting
Head lice is a stigmatizing condition –
Socially discredited–
Set apart from others–
Stigma increased if •
Treatment was unsuccessful•
Re-infestation occurred •
Infestation becomes chronic
“I over heard my son’s best friend’s mother say it wasn’t safe to come over to our house.”
Stage I Being Ostracized
Exaggerating meaning
Blaming the victim
Ruminating
Stage I Being OstracizedExaggerating meaning and negatively evaluating ability to successfully treat lice.
Blaming the Victim. Persistent head lice is thought to be a curable condition that is allowed to become chronic by the parents/caregivers.
Ruminating–
Intrusion of unwanted thoughts that interfere with daily functioning.
“I’ve been trying to get rid of these things for 4 years! No matter what –they keep coming back. You start to believe you will never win.”
“They keep telling me I must be doing something wrong. I’m following all of the instructions to the letter. My house is clean. It [lice] just keeps coming back.”
“I think about it [lice] all the time. I can’t sleep. I feel them crawling even when they are not there.”
Stage II Losing Integrity of the Self
Participants described losing integrity of the self as a consequence of being ostracized.
“It [head lice] changes how people see you – how you see yourself”
Stage IILosing Integrity
of the Self
Enduring Social Isolation
Altered Family Interactions
Feeling Guilty
Stage II Losing Integrity of the Self
Enduring isolation–
Social isolation is shared
Feeling guilty–
Expectation that “good”
parents can successfully treat lice
Altered family interactions–
Effects day-to-day family relationships
“They only let her come to school for the FCAT exam. They made her sit on a plastic chair away from her friends. It makes me cry to think about it”.
“My husband is clueless, he’s like What’s going on? Why can’t you just take care of this? Like it’s that easy. I don’t now why!”
“When I lay down at night to read to her, we both wear shower caps to keep our heads from touching”
Stage III Struggling with Persistence
Participants described strategies developed to cope with caregiver strain and shared vulnerability experienced in caring for children with persistent head lice.
“It’s a struggle everyday. You get up knowing you have to deal with it [lice] and you go to bed dreading the next day.”
Stage IIIStruggling with
Persistence
Protecting AgainstExposure
Trying Everything
Seeking Help
Stage III Struggling with Persistence
Protecting against exposure–
Lice secret–
transmission
Trying everything–
Feeling overwhelmed and desperate
Seeking help
“I don’t let her go to anyone’s house or have anyone over. I just can’t risk it.”
“I can’t remember what all I’ve used. This has been going on for years. Sometimes I got pretty desperate – I used bleach, hair dye, kerosene, bug spray. I needed real help.”
“I tried to see my son’s doctor – he said talk to the pharmacist. He didn’t want my son to come in the office!”
Stage IV Managing StrainAs a consequence of struggling with persistence, participants managed strain day to day.
“You have to learn to deal with the stress on a daily basis. What else can you do? Some days are better than others.”
Stage IVManaging Strain
Gaining Perspective
Balancing Resources
Developing Trust
Stage IV Managing StrainGaining perspective–
alternated between seeing head lice as a major health threat and a benign condition.
Balancing resources–
Financial & human
Developing trust–
Share the secret
“ Sometimes I think head lice never killed anyone – but then I think I will never live through this.”
“My husband and I trade off. Sometimes he stays home with the kids. I couldn’t do this alone.”
“At some point you just have tell people and trust they do the right thing by checking their own kids and not making a personnel issue out of it.”
Implications for School Nurses:
↑ Understanding of potential effects of persistent head lice on the family as a whole–
Shift from blaming → supporting
Challenge existing approaches → Grounding nursing responses in “what matters most.” (Boykin &Schoenhofer, 2001, p. 59.)
What mattered most to participants in this study was caregiver strain.
Family Centered Strategies - Working Together:
Conceptualize head lice as a family phenomena–
Focus on contact tracingRecognize the strain placed on caregiversShift from adversarial approaches–
Evaluate exclusion policiesEducational programs to reduce stigma–
Community and school basedOffer treatment options respectfully–
How can I help?Co-ordinate community efforts–
Increase referrals for lice treatment–
Seek funding opportunitiesEnhance participation in research studies
References:
Burgess, C.G., Pollack, R. & Taplin, D. (2003). Cutting through the Controversy: Special Report on the Treatment of Head Lice.Morrristown, NJ: Premier Health Care Research.
Gordon, S. ( 2007). Shared Vulnerability: A theory of caring for children with persistent head lice. Journal of School Nursing, (in press)
Gordon, S. (2004). School nurse attitudes toward the standardization of head lice policies. Unpublished manuscript.
Gordon, S. ( 1999). Factors relating to the overuse of chemical pesticides in children experiencing persistent head lice. Journal of School Nursing, 15(5), 6-10.
References:Pollack, R.J, Kiszewski, AE, Spielman, A. (2000), Over diagnosis & consequent mismanagement of head louse infestations in North America. Pediatric Infectious Disease, 19, 689-693.
Roberts, RJ, ( 2002). Head lice. New England Journal of Medicine, 346, 1645-1650.
Williams, LK, Reichert, A. MacKenzie, WR, Hightower, AW, Blake, PA. (2001). Lice, nits, and school policy. Pediatrics, 107, 1011-1015.