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Back to School? The 'No Nit' Policy.

Did you know that September is National Head Lice Prevention Month? Although infestation can occur throughout the year, a peak is usually experienced during summer and back-to-school time periods (Hansen, 2004). Celebrating its 25th National Head Lice Prevention Campaign, the National Pediculosis Association (NPA) hopes to help parents, teachers, and students understand the communicability of head lice before outbreaks occur (NPA, 2010). The NPA, founded in 1983, is a non-profit volunteer organization dedicated to protecting children from the misuse and abuse of potentially harmful lice and scabies pesticide treatment. This organization initiated and continues to advocate for the "no nit" policy for schools. The no-nit policy requires children to be free of nits, the empty casings left behind by lice once they hatch from their eggs, before they may return to school.

The National Association of School Nurses (NASN) and the American Academy of Pediatrics (AAP) have discouraged this policy because it has not proven to lower overall infestation rates and puts children who miss class at a disadvantage (Frankowsk, Weiner, & Council on School Health and Committee on Infectious Disease, 2002; NASN, 2004). However, an August 2010 update to AAP's guidelines uses even stronger language to urge schools to abandon their strict no-nit policies (Frankowski, Bocchini, & Committee on Infectious Diseases and Council on School Health, 2010).

The announcement of this recommendation resulted in a flurry of "ewww," "ick," and "yuck" responses on Pediatric Nursing's Facebook page. These responses prompted a review of the literature to examine the evidence that supports rejecting the no-nit policy.

Pediculosis Capitis

Because head lice infestation is not a reportable disease, it is difficult to calculate its prevalence. Basing figures on sales of pediculicides, it is estimated that approximately 6 to 12 million infestations, primarily children 3 to 12 years of age, occur each year in the United States (Meinking & Taplin, 2003).

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Diagnosing head lice can be tricky. The gold standard is finding a live louse on the head, which can be difficult because lice avoid light and can crawl quickly. Unlike body lice, head lice do not transmit any disease agent (Elston, 2005). A sensitized individual, however, can develop itching. Resulting scratching may, in rare circumstances, cause impetigo or other skin infection, which can lead to local adenopathy (Frankowski et al., 2010).

Because lice cannot hop or fly, transmission in most cases occurs by direct contact with the head of an infested individual (Frankowski et al., 2010). Much less likely but possible, lice may be spread indirectly through contact with personal belongings of an infested individual (such as combs, brushes, hats). The major focus of control activities, therefore, is to reduce the number of lice on the head and to lessen the risks of head-to-head contact.

The School's Response

Each year about 1 in every 100 elementary school children in the United States becomes infested with head lice (Pollock, 2007). Through a school screening or a teacher's concern, a student may be identified as infested. What happens next? In some cases the school contacts the child's parents and instructs them to come and remove the child from school immediately. But is this really necessary? Frankowski and colleagues (2010) point out that because a child with an active head lice infestation likely has had the infestation for one month or more by the time it is discovered, he or she poses little risk to others by staying the remainder of the day. Of course, during this time the child's close direct head contact with others should be discouraged.

'No Nit' Policies

According to Hansen (2004), the most serious consequences of head lice include the social cost of missed school days, and associated cost of lost productivity and wages of parents who must care for children sent home from school. No-nit policies result in approximately 12 to 24 million school days lost annually in the U.S. (Scott, Gilmer, & Johannessen, 2004). This adds up to an average of 20 missed days per student (Hansen & O'Haver, 2004). In some instances, children have missed so much valuable school time that they have needed to repeat a grade (Pollack, Kiszewski, & Spielman, 2000).

But do these "zero-tolerance" policies work? Misidentification resulting in misdiagnosis is a significant issue. Pollack and colleagues (2000) collected over 600 samples of what parents, doctors, and nurses said were head lice or nits. Upon examination, they found that less than two in three samples were actually what people thought they were. Only about one in two samples found to be nits contained baby head lice capable of hatching. The rest were either empty or contained a louse that would not have hatched. Misdiagnoses result in the unnecessary use of over-the-counter and prescription pediculicides. As with antibiotics, overuse of pediculicides can lead to resistance.

Pollack et al. (2000) reported two additional important findings regarding no-nit policies. First, schools with no-nit polices showed no fewer cases of lice than those without the policies. And second, non-infested children are excluded from school because of presumed pediculosis more frequently than infested children.

As mentioned previously, both NASN and AAP discourage no-nit policies. Nevertheless, Frankowski and colleagues (2010) report that nit removal may be considered for the following reasons:

* Nit removal can decrease diagnostic confusion.

* Nit removal can decrease the possibility of unnecessary re-treatment.

* Some experts recommend removal of nits within 1 cm of the scalp to decrease the small risk of self-reinfestation.

Nursing Implications

The school nurse has a leadership role in preventing and controlling the spread of head lice infestation in the school setting. NASN's S.C.R.A.T.C.H. Head Lice Community Education Program offers many excellent resources to help in this regard (see http://www.nasn.org).

In an effort to stop the spread of head lice by identifying children who are infested, some schools initiate screenings. However, screening for nits alone is not an accurate way of predicting which children are or will become infested, and screening for live lice has not been proven to have a significant effect on the incidence of head lice in a school community over time (Counahan, Andrews, Buttner, Bymes, & Speare, 2004; Meinking & Taplin, 2003). If a school or school district mandates screening, the school nurse can schedule the screening on a Friday to enable children who are identified with infestations to be treated over the weekend and be ready to return to school on Monday, with no loss of school time.

The evidence tells us that no-nit policies are ineffective and should be abandoned. School nurses, as well as nurses in offices, clinics, and other practice settings, can perform a valuable service by providing parents and schools with up-to-date, scientific information about head lice, and offer additional assistance to families of children who are repeatedly or chronically infested.

Sciscione and Krause-Parello (2007) acknowledge that a policy allowing students who are not nit-free to remain in school may face some staunch opposition. Lack of knowledge coupled with the "ewww" factor can heighten anxiety. Frankowski and colleagues (2010) remind us that head lice are not a health hazard or a sign of poor hygiene, and in contrast to body lice, are not responsible for the spread of any disease. Children with symptoms of a cold or flu are rarely sent home, yet it is much easier for a child to catch a cold or the flu at school than it is to contract head lice.

It appears that the growing medical evidence is helping more school districts to ease up on restrictive return-to-school policies. According to Martha Bergren, director of research for NASN, increasingly over the past year, school boards across the country have accepted that lice do not represent enough of a public health threat to keep children at home, and have abandoned their no-nit policies (Bergren, as cited by Park, 2010, para. 10): "What we are seeing is much less resistance to changing the policy, and the tide is turning."

References

Counahan, M., Andrews, R., Buttner, P., Bymes, G., & Speare, R. (2004). Head lice prevalence in primary schools in Victoria, Australia. Journal of Paediatrics and Child Health, 40(11), 616-619.

Elson, D. (2005). Drugs used in the treatment of pediculosis. Journal of Drug Dermatology, 4(2), 207-211.

Frankowski, B., Bochini, J., & The Council on School Health and Committee on Infectious Disease. (2010). Clinical report-head lice. Pediatrics, 126(2), 392-403.

Frankowski, B., Weiner, L., & The Council on School Health and Committee on infectious Disease. (2002). Clinical report-head lice. Pediatrics, 110(3), 638-643.

Hansen, R. (2004). Overview: The state of head lice management and control. American Journal of Managed Care, 10, S260-S263.

Hansen, R., & O'Haver, J. (2004). Economic considerations associated with pediculus humanus capitis infestation. Clinical Pediatrics, 43(6), 523-527.

Meinking, T., & Taplin, D. (2003). Infestations. In L.A. Schachner, & R.C. Hansen (Eds.), Pediatric dermatology (3rd ed.) (pp. 1141-1180). St Louis: Mosby.

National Association of School Nurses (NASN). (2004). Position statement: Pediculosis in the school community. Retrieved from http://www.nasn.org/ Default.aspxtabid=237

National Pediculosis Association (NPA). (2010). For this year's National Head Lice Prevention Campaign, the National Pediculosis Association says comb first. Retrieved from http://www.headlice.org/ news/2010/comb-first-back-to-school2010.html

Park, A. (2010). Report: Head lice is no reason to keep kids out of school Retrieved from http://www.time.com/ time/health/article/0,8599,2006397,00. html

Pollack, R. (2007). The role of the school in batting head lice. Retrieved from http://www.pta.org/2151.htm

Pollack, R., Kiszewski, A., & Spielman, A. (2000). Overdiagnosis and consequent mismanagement of head louse infestations in North America. Pediatric Infectious Disease Journal, 18, 689-693.

Sciscione, P., & Krause-Parello, C. (2007). No-nit policies in schools: Time for change. The Journal of School Nursing, 23(1), 13-20.

Scott, P., Gilmer, J,. & Johannessen, W. (2004). The nit rating scale. Journal of School Health, 74(3), 108-110.

Judy A. Rollins, PhD, RN
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Title Annotation:From the Editor
Author:Rollins, Judy A.
Publication:Pediatric Nursing
Article Type:Report
Geographic Code:1USA
Date:Sep 1, 2010
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