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.