Date published: August 1, 2012
Journal code: CPRA
As a community practitioner, you have a vital role to play in providing parents and schools with support and practical advice. This section provides best-practice advice to help you guide your clients.
LESSONS IN LICE
Ideally, parents of primary school children should receive advice about head lice on a regular basis - not just when concerns are raised or in reaction to an outbreak.6 Letters notifying parents about outbreaks in school can produce unnecessary alarm and inappropriate prophylactic treatment and are not advisable. Instead, school nurses should work with their primary schools to ensure every parent receives appropriate and consistent head lice information (see Box 1 ) - preferably as part of a package with other issues - before their child joins the reception class and at regular intervals throughout each school year. Health visitors can support this process by presenting head lice advice as early as the 18-month screening and reinforcing mis at the pre-school stage.
Schools may be just as misinformed as parents, so it is useful if school nurses share advice with school staff too. And, all community practitioners should be prepared to teach the appropriate detection technique and recommend suitable treatment options.
The most reliable way to determine if a child has head lice is to systematically comb through their hair using a lice detection comb. These reusable plastic combs have parallel-sided teeth, spaced <0.3 mm apart - close enough to trap the smallest nymph.1 Detection combing can be done when the hair is wet or dry, but a recent review concluded that wet combing was me optimal method.7 Having to wash the child's hair and apply conditioner makes wet combing a little more time consuming. However, the conditioner makes combing easier (for both parties) and helps stop the lice crawling away. The sensitivity of the wet combing method is >90% - even when very few lice are present.7
Parents need to understand that the school nursing service doesn't routinely screen children for head lice and that this is a parental responsibility. As detection combing takes 5 to 15 minutes per head (depending on hair length), thorough screening of every child at school is not feasible. Community practitioners should encourage parents to check their children's hair for lice regularly using the correct method (see Box 2). Ideally, parents should do this once a week as part of their child's usual hygiene routine - perhaps every Sunday evening or at bath time. It is important to emphasise that nits are empty lice eggs and that finding nits in their child's hair doesn't necessarily mean that they have head lice. Live lice must be seen to confirm the diagnosis.
BREAKING THE CYCLE OF INFECTION
If a parent finds a live louse on their child's hair, they should ensure that all other household members (including themselves) have their hair checked by detection combing. Those found to have head lice (or their parents) should contact anyone likely to have recently had head-to-head contact and advise them to check for lice too. Parents should be reminded that this could include:
* siblings, grandparents and other relatives
* friends and classmates
* teachers and childminders
* after-school clubs/teams (e.g. rugby team, dance class, Cubs, Brownies, etc.).
Parents may be embarrassed about contacting others, but this is necessary to break the cycle of infection and help stop their child being re- infected. Ideally, all contacts found to have live head lice would be treated simultaneously.
SCHOOL HEAD LICE POLICIES
Parents need to understand that regular detection combing and prompt treatment are necessary to stop head lice spreading, but that mere is no need for children with head lice to be kept away from school or any other setting.8 Head lice are not a major health problem and children shouldn't miss valuable schooling because of them. In many cases, the lice will have been present long before detection anyway.
Once head lice are confirmed, parents should be advised to treat the problem as quickly as possible using one of the clinically proven treatment options (see Figure 2).1
One option is to physically remove the lice by wet combing. This requires at least four combing sessions over a 2- week period, continued until no lice are seen for three consecutive sessions. The method is similar to detection combing (see Box 2) but takes longer as the comb must be carefully cleaned of lice after every stroke, and the procedure has to be repeated after washing out the conditioner. The method is suitable for all ages and can be recommended as an option for pregnant and breastfeeding women. However, the process is laborious and timeconsuming - especially for parents who need to treat several family members at the same time. Even with meticulous combing it only offers a 50-60% success rate.1
Topical pediculicides can provide parents with a more effective and convenient way to tackle head lice. There are two main types. Chemical pediculicides (also known as neurotoxic or traditional insecticides) kill head lice by disrupting their nervous system. Physical pediculicides kill lice by coating them in an oily substance, causing them to dehydrate or suffocate.
Treatments to recommend (where suitable) include the chemical pediculicide, malathion 0.5% aqueous liquid - a waterbased formula that kills lice and eggs when applied overnight, or one of the physically acting pediculicides:
* isopropyl myristate/cyclomethicone solution (IPM/C)
* coconut, anise and yiang ylang spray, or
* dimenarne 4% lotion.
Head lice have increasingly developed resistance to older chemical pediculicides, such as permethrin. However, resistance is unlikely to develop with the physical pediculicides, so complex rotational or mosaic treatment policies are not necessary when using these.
Parents may seek your advice about which treatment they should try. Success rates are generally highest with the physical pediculicides, but there are various other pros and cons to consider.1 For example, dimeticone 4% lotion must be applied for 8 hours, whereas IPM/C has a quick and easy 10-minute treatment time (see Figure 2). Whichever option parents select, it is important to check its suitability for their child (or anyone else needing treatment) and remind them to follow the instructions carefully.
You should explain to parents that they could maximise their chances of success if they treat all affected contacts simultaneously and apply the treatment correctly (according to the instructions). Most treatments require a second application after 7 days because the first might not kill all the louse eggs. The second application kills the lice that hatch in the intervening period. Parents should be encouraged to check treatment success by detection combing 2-3 days after completing a course of treatment, and again 7 days later.1 Do remind parents that it is usual to find empty egg cases (nits) long after the lice have gone. They can use a fine- toothed nit comb to remove these.
PERSISTENT LICE PROBLEMS
When a parent reports that a treatment hasn't worked, there are several possible explanations:
* use of treatment formulation of unproven efficacy (e.g. shampoo and mousse)
* treatment not applied correctly (e.g. insufficient volume or treatment time)
* re-infection due to affected close contacts not being treated simultaneously
* head lice resistant to treatment (not an issue with physical pediculicides).
Families with recurrent or continuing head lice may need your support to deal with the problem. This may involve visiting the family at home. It is vital to check that the child actually has an ongoing head lice problem, recommend all close contacts are checked, and reiterate appropriate treatment advice. If you suspect a genuine treatment failure, you should advise the parent to try one of the alternative treatment options.