Supplements Definitive Management of Head Lice in the Era of Pediculicide Resistance
Treating and Managing Head Lice: The School Nurse Perspective
School nurses often are the first healthcare professionals to diagnose lice infestations in children. Although lice do not transmit disease, many schools send children home if they detect live head lice. It is the position of the National Association of School Nurses that children who have been treated for lice infestations should not be excluded from school because of the presence of residual nits.
The primary goals of the school nurse in controlling infestations are to identify children with head lice and to break the cycle of reinfestation. Routine screening of children for head lice is often part of infestation management policies in school districts. A thorough screening of a child's head can take several minutes. If a school's policy is to screen all students, the total time for examination adds significantly to the school nurse's caseload. The use of the school nurse's time for universal screening must be measured against other responsibilities, including health problem management, medication management, health assessments, and vision and hearing screening.
Once a child is identified as having lice, the school nurse can play a key role in working with the child's family to eradicate the infestation. Education about treatment options and environmental cleaning are topics the nurse can address with the family. The school nurse also can function as a case manager who coordinates various aspects of treatment for an affected child. Because infestations can be very upsetting to students and to their families, the nurse can provide support and reassurance to the family as the child is treated. Participation of school nurses in developing appropriate and consistent policies and procedures within the school district is vital to the overall management of infestations. Their efforts to control and reduce infestations are necessary for the overall health of the school population.
(Am J Manag Care. 2004;10:S273-S276)
Goals of Head Lice Management
The school nurse holds a unique and vital
role in the diagnosis and management of
head lice in children. As the primary healthcare
provider in a school, the nurse is often
the first health professional to assess a child
for the presence of head lice. While lice do
not transmit disease, an infestation is a community
problem that is innocently brought
into the schools by children. It is the position
of the National Association of School
Nurses (NASN) that children not be excluded
from school following treatment for
head lice. But, because pediculosis can be
alarming and disconcerting to students,
their families, and members of the school
community, the school nurse's involvement
is key to successful management.
The primary goals of the school nurse in
effectively managing lice infestation are to
work with families to identify infested individuals,
to break the cycle of infestations,
and to return affected children to class
quickly. Identification of infestations
requires proper equipment and adequate
time for examination. Optimal examination
equipment includes a lighted magnifier with
an ultraviolet light source. If a lighted magnifier
is not available, at a minimum the school
nurse should have a gooseneck lamp with at
least a 60-watt bulb. Disposable sticks or
applicators are recommended to separate the
hair during examination. A thorough screening
of a student's head can take several minutes
per student. When an entire classroom
of 25 students must be assessed, the total
time for examination represents a significant
addition to an already busy daily caseload in
the school health office. A positive identification
of infestation is indicated if live lice or
nits are found.
The second step after identifying the presence
of head lice in a school population is to
break the cycle of reinfestation through careful
and repeated communication with the
families of affected students. Parents must be
educated about appropriate pediculicidal
treatment and environmental cleaning, for
example. These activities are vitally important
in the successful treatment of an infestation,
but there are many additional aspects to
stopping infestations. These include promoting
shared responsibility, developing appropriate
and consistent management policies
and procedures, providing comprehensive
education, and outlining screening measures
and guidelines for special situations.
Shared Responsibility: A Multidisciplinary
Approach. School nurses can function
as case managers for many health
concerns, but pediculosis is one in which
they can provide a leadership role in working
with others who must participate to successfully
control lice infestations. It is vital
that all members of the school community
assume responsibility as part of the school
team, especially in areas where a school
nurse may not be employed full time. As a
part of this multidisciplinary approach, the
school nurse may have contact with the family
of an affected student, school administrators,
members of the school community,
and, ideally, the physician and pharmacist
who provide medical treatment. This effort
can be extensive and might involve more
than 1 household. Providing consistent and
comprehensive communication and leadership
to everyone involved produces the most
favorable outcome for the student. The
school nurse also must be able to coordinate
care while respecting the child's right to
confidentiality. In addition, the school nurse
must be able to direct care in a manner that
promotes the use of evidence-based treatments
rather than home remedies conveyed
through hearsay in the community.
Policies and Procedures. School districts
are advised to research and create
sound and practical policies and procedures
for dealing with pediculosis. These policies
should be developed within the scope of
local and state laws, public health guidelines,
recommendations from the NASN, and
with the support of the district's school
physician, where there is one. The school
physician and the school nurse will find that
the head lice clinical information from the
American Academy of Pediatrics and the
position statement of NASN are compatible
in treatment methodology, allowing for a
strong collaborative approach between the
medical and nursing disciplines.1,2
It is advisable for the school administration
to work with the school nurse to put
policies and procedures in writing for the
school community to ensure consistent and
appropriate care. A thorough procedural
document will include a description of lice
screening processes to be followed by the
school, information about how parents and
the community will be notified of an infestation,
and the treatment protocol. Specific
parameters outlining when it is necessary to
notify public health officials of a significant
outbreak also should be included. Although
they are important, detailed procedures
must be viewed as guidelines rather than
rigid rules, with each situation involving
some individual consideration.
The implementation of nit-free or no-nit
policies in schools has stirred concern
among healthcare providers. A pediculosis
position statement adopted by the NASN in
1999, and revisited in 2004, states that nit-free
policies disrupt the educational process
and should not be viewed as an essential
strategy in the management of head lice.
Data do not support school exclusion for
nits. Since no disease process is associated
with head lice, schools are advised not to
exclude students for nits remaining after lice
treatment, although further monitoring for
signs of reinfestations is appropriate. The
school nurse, as student advocate and nursing
expert, should be included in school district-community planning, implementation,
and evaluation of vector control programs
for the school setting. The school nurse
retains an important role in educating all
constituencies about pediculosis and dispelling
myths and stigmas regarding lice
infestation.1,3,4 School districts are advised
to address the issue of nit-free policies prior
to a potential infestation.
Education. The school nurse has to be
prepared to provide comprehensive education
to all stakeholders in the school community
when lice have been identified. The
effectiveness of education is dependent on
addressing the specific needs of the group,
such as language barriers or the level of education
of parents or guardians. It is important
to provide information proactively as
well as during infestations. The most effective
approach is to design and present information
in different formats to reach the
intended audience in a way that is meaningful
and can be followed.
Providing quality education necessitates
staying current with treatment practices and
understanding misinformation that may be
associated with lice and the treatment of
infestations. The school nurse should make
every attempt to research and address misinformation
about lice and treatments for infestation
prior to the dissemination of school
information to give family members and others
a chance to ask questions and to learn
about the lice management practices recommended
by the school. Addressing misconceptions
prior to an infestation may expedite
the use of evidence-based treatments.
Screening Programs. Screening is defined
as the identification of unrecognized
cases through examination, tests, or other
procedures. The criteria for screening are
determined by the nurse and the school
administration. Some school districts choose
to screen all students when they enter class
in the fall or return after school breaks.
These universal school-based screenings are
intensive, requiring substantial organization
and collaboration. Because of their comprehensive
scope and the time required by the
school nurse to oversee them, universal
screenings should be considered only during
high rates of infestation. (High rates should
be defined by the district in their stated policies
and procedures.)
The use of school nurses' time for a general
lice screening has to be measured
against their other responsibilities, including
health problem management, medication
management, health assessments, vision
and hearing screening, and many other vital
activities. Some schools choose selective
school-based screening to evaluate only students
in high-risk groups or students who
are symptomatic. In some cases, the school
may ask parents to examine their children,
particularly before the first day of school.
There is concern, however, regarding the
adherence and accuracy of family-based
screening. Family members may be inexperienced
in identifying lice and should be provided
with information and support if they
suspect that they have found lice.
A collaborative team approach to discerning
the needs of a particular school district
can be determined by considering the history
and number of reported cases in the
school district, the seasonal incidence of
cases, and the community level of concern
during the year.
Role of the School Nurse
The school nurse is a key individual who
can offer reassurance and support for the
family and act as an advocate. The nurse frequently
has the opportunity to establish
relationships with students and families
and is often perceived as an ally. If a student
is identified as having an infestation, the
school nurse can offer support and encouragement
through face-to-face conversation,
frequent phone contact, or written material
that can be sent home with the student. In
addition to providing personal support, the
school nurse is an ideal case manager who,
with the support of the school community,
can be very effective in educating the family
and providing resources to help students and
their families treat infestations.
Having lice may carry a significant social
stigma, so it is not unusual for parents to
become distressed and openly upset when
their child is diagnosed. Parents also may
feel overwhelmed by treatment concerns,
questions regarding pediculicides, and what
they need to do to clean their homes, cars,
and clothing to eradicate the infestation.
The school nurse can provide support,
advice, and information. When parents are
willing and able to adhere to a comprehensive
treatment approach, the chances of
eradication of infestation and a positive outcome
are greatly increased.
Conclusion
The school nurse is often the first health
professional to assess a child for lice infestation
and may be the first resource to help
parents care for their child. School nurses
are responsible for the care of individual
students, but they also have responsibility
for the entire population of students. Their
efforts to control and reduce infestations are
necessary for the overall health of the school
population.
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