National Guidance on Managing Head Lice Infection in Children
Head lice are a common problem, which can affect anyone, but are most prevalent amongst children.
This national guidance has been written to clarify the respective responsibilities of the health service, local authorities and schools, and other care services on managing head lice infection in children. We are aware that there is currently a lack of consistency and clarity in the advice provided for parents and carers across Scotland. This guidance is intended to address that by promoting a more consistent approach to policy and practice.
We want to ensure that all children and their families or carers
have access to accurate,
up-to-date and impartial advice and support on detection and treatment of head lice. The Health Education Board for Scotland (HEBS) is preparing a leaflet for parents to complement the advice provided for professionals in this guidance.
Many colleagues and partners from health and education backgrounds have contributed to the development of the guidance and we are very grateful to them. All NHS Boards, local authorities, school nurses, head teachers and a wide range of other health and education professionals, now have an important role to play in taking forward this guidance to ensure effective management of head lice infection in children. A sustained and joined up approach from everyone involved will ensure that the problem is dealt with effectively, and without stigmatising children or families.
Malcolm Chisholm, MSP
Cathy Jamieson, MSP
Head lice are a common problem, which can affect the whole community, adults and children alike. However, head lice infection is most common amongst children and this guidance is intended to offer advice to health, education and social work professionals on managing head lice infection in schools and other child care settings such as hospitals, nurseries, out of school clubs and residential and foster care. Although this guidance is aimed specifically at the management of head lice infection in children, the same principles would apply for the management of head lice infection in adults.
The 1998 Stafford Report, Guidelines on the Diagnosis and Treatment of Head Lice, gave rise to changes in the way head lice infection is managed and where the responsibility for detection lies. This guidance seeks to disseminate learning from the Stafford Report and take forward implementation of some of its recommendations.
The Stafford Report states:
'Head lice are not primarily a problem of schools, but of the community. Stigma and tradition, however, combined with inadequate public and professional knowledge continue to hold schools responsible.'
Effective management of head lice infection depends on the ability of all relevant professionals/agencies to offer clear, accurate and impartial advice and support to parents on detection and treatment.
The control of head lice is not the responsibility of any one agency alone.
Most NHS Boards in Scotland have developed their own guidelines on the management of head lice infection. Whilst dealing with the problem remains a local responsibility, the Scottish Executive is aware of concerns about the current lack of consistency in the advice and procedures for managing head lice infection across Scotland. This guidance therefore seeks to promote a more consistent approach to policy and practice.
Throughout this guidance, the term "parents" includes all those with parental responsibility, including carers.
What are head lice?
Head lice are small, six-legged wingless insects which are pin-head size when they hatch, less than match-head size when fully grown and are grey/brown in colour. They are difficult to detect in dry hair even when the head is closely inspected. Head lice can cause itching, but this is not always the case.
Images to Assist in the identification of head lice and their eggs
1. Adult female louse on nit comb
2. Viable egg on hair -2days old
3. Viable egg -1 day before hatching
4. Empty egg (hatched)
5. Dead egg (>2 weeks old)
6. 'Pseudo-nit' (Debris often confused as eggs)
©2000 President and Fellows of Harvard College http://www.hsph.harvard.edu/headlice.html
Head lice live on, or very close to, the scalp at the base of the hair, where they find both food and warmth. They feed through the scalp of their host. The female louse lays eggs in sacs which are very small, dull in colour and well camouflaged. These are securely glued to hairs where the warmth of the scalp will hatch them out in 7 to 10 days. Nits are the empty egg sacs, which are white and shiny and may be found further along the hair shaft as the hair grows. Nits are often easier to see than the head lice themselves. Many people mistake the empty egg sacs - or 'nits' - for head lice or believe that it is evidence of an active head lice infection. This is not true; it is evidence of a previous infection.
A head lice infection cannot be diagnosed unless a living louse has been found on the head.
During their life span of one month, head lice will shed their skin up to three times. This skin, combined with louse droppings, looks like black dust and may be seen on the pillows of people with head lice.
Head lice cannot fly, jump or swim; they are contracted only by direct head to head contact. Contrary to popular belief, the length, condition or cleanliness of hair does not predispose any particular group to head lice infection.
Anyone with hair can catch head lice, meaning that the problem, whilst often more prevalent in children, is not unique to them.
Whilst cleanliness is not related to contracting a head lice infection, regular hair washing and combing does offer a good opportunity to detect any infection so that it can be treated. Head lice cannot be prevented, but daily hair brushing and grooming can aid early detection.
The Stafford Report states that,
'The primary responsibility for the identification, treatment and prevention of head lice in a family has to lie with the parents, if only for reasons of practicality. Parents however, cannot be expected to diagnose current infection, or distinguish it from successfully treated previous infection or other conditions if they are not adequately instructed and supported by health professionals.'
Previous practice relied on the school nurse conducting regular inspections of pupils for head lice. The Stafford Report recommends that parents are best placed to be responsible for regularly checking their children for head lice. There are sound reasons for this.
The first, and most important, is that 'wet combing' (see below) is the only truly effective way to carry out an inspection. Inspections in school by the school nurse were conducted on dry hair and were not, therefore, effective. To be effective, inspection also needs to be done on a regular basis. Inspection of a whole class of school children on one day will not detect a child who may become infected the next or any other day. School inspections are time consuming and can never be done on a sufficiently regular basis to make any real impact.
The Stafford Report also highlighted the importance of de-stigmatising the identification of head lice for children and parents, by moving away from school inspection.
Regular checking of children's heads is important, but it is a parental responsibility.
Education and health professionals do, however, have a key responsibility to offer supportive advice to parents about how to identify and treat infections effectively.
Head lice infection can be distressing and disturbing for children and parents. However, head lice are not harmful, and children and parents should be re-assured that having head lice is nothing to be ashamed of. There are many misleading notions about head lice, and helping parents and children to understand the facts is crucial in de-stigmatising head lice infection.
Schools have a key role in this, and can provide valuable support by issuing comprehensive information about head lice detection and treatments to parents that includes information about sources of advice.
The Stafford Report highlighted that weekly checks, by 'wet combing', are the most effective method of detection.
'Wet combing' involves washing the hair and applying conditioner, then combing through with a wide-tooth comb to remove tangles. Taking a section at a time, a fine tooth detection comb is then pulled downwards through the hair, keeping the comb close to the scalp (where head lice are often located). The comb is checked for lice after each section. The comb must be fine enough to catch the lice and a pharmacist should be able to recommend a comb for this purpose, if parents are in any doubt. This process should be completed weekly. If head lice are found, all other family members should be checked and, if necessary, treated. Checks should be continued following treatment to ensure that it has been effective and to detect any re-infection.
Once infection is detected, there are two treatment approaches. One option is the use of insecticide lotions and an alternative is removal by wet combing, sometimes called 'bug busting'. Both methods require continued combing to remove any unhatched eggs.
Parents should be offered information on both approaches so that they can make an informed decision for their family.
Re-infection can occur if a child has direct head to head contact with someone else who has head lice. It is likely that a child will become re-infected unless the whole family, and all those who have been in close contact with the child, have been checked and, if live lice are found, treated.
There are a number of different insecticide lotions available and pharmacists, GPs and school nurses should provide advice to parents about these on request or where they have identified/confirmed the presence of a head lice infection. School nurses, health visitors, pharmacists or GPs can give advice on which particular lotion is the most effective. The advice of a health professional should also be sought where whoever is being treated is under 1 year of age, suffers from asthma or allergies, or is pregnant or breastfeeding.
One treatment using insecticide lotions involves two applications of the same insecticide, seven days apart. This is because insecticide lotions do not kill any eggs that may be present at the time of the first application. If eggs hatch and are not treated, the infection will continue. This treatment should be applied by parents at home.
If live head lice are discovered after the second application, the advice of a health professional should be sought before any further lotion treatment is applied.
Insecticide treatment should never be used as a preventative measure as the use of insecticidal products on a regular basis may result in insecticidal resistance. Insecticide lotions should only be used when a living louse has been found on the head.
An alternative option for dealing with head lice is wet combing, sometimes called 'bug busting'. This is a non-chemical approach that involves mechanical removal of all lice from the hair after the hair has been washed and conditioned. With the conditioner still in, the hair is combed gradually using a fine tooth comb, section by section, in order to remove the lice.
'Bug busting' is time consuming and to be effective, must be carried out every 3 days for up to 3 weeks to remove newly hatched lice. Insecticide treatments offer a more immediate solution to a head lice infection, but some parents may have concerns about using these sorts of treatments.
The 'Bug Buster Kit' is now available for prescribing by health professionals. Only one kit is required for a family and it is reusable. The kit, which includes an illustrated guide and combs, is available from some pharmacies and by mail order from:
Community Hygiene Concern (Charity reg no: 801371)
6 - 9 Manor Gardens
Help Line: 020 7686 4321
As there is little evidence of clinical effectiveness, we cannot recommend the use of alternative methods of treating head lice such as aromatherapy, tea tree oil or 'electronic zappers'. However, the guidance will be updated should new evidence come to light.
Prescription of treatments
District nurses and health visitors (and those practice nurses who have a district nurse or health visitor qualification) who have had additional training are allowed to prescribe from a limited Nurse Prescribers Formulary, which includes head lice treatments. The number of nurses who are able to undertake this training will increase from April 2002, and the formulary will be widened to cover all over the counter medicines including all pharmacy only medicines and around 140 prescription only medicines. We anticipate that a significant number of practice nurses will adopt this new role, as will some school nurses.
The Scottish Executive, through The Right Medicine: A Strategy for Pharmaceutical Care in Scotland, is working towards allowing community pharmacists to prescribe medicines free of charge to treat common conditions, such as head lice, for those who are normally exempt from prescription charges, to save them having to visit their GP for a prescription.
A Patient Group Direction (PGD) may be an effective local mechanism to improve access to head lice treatments. A PGD is a locally agreed protocol, produced within an established framework which allows nurses (or others, including pharmacists) to issue a specified medication to a specified group of patients in specified circumstances.
Families will be able to get free prescription treatments for head lice infection for their children from a variety of sources, and will not have to wait for a GP appointment.
'Alert letters' should not be sent to the parents of other children in the class of a child who may be infected with head lice. There is more than one reason for this.
Firstly, 'alert letters' are not routinely sent out for other, more communicable diseases or infections. Secondly, most schools are likely to have a few pupils with head lice at any one time. On that basis, an 'alert letter' could potentially be required every day of the school year.
'Alert letters' also often lead parents to believe that there is an 'outbreak' when in fact, only one child in the class may be infected. Those parents might then treat their own child preventatively, which is neither necessary nor advised.
Only the parents of a child who appears to have a head lice infection should be informed, in writing or by telephone. This should be handled sensitively as it may be distressing for parents. Schools should also take account of the needs of parents for whom English is not their first language, or who may have difficulty in reading.
Schools, working with the school nurse, should helpfully provide parents with information about the detection and treatment of head lice infection in a proactive and systematic way, at the start of every new term as well as at any point in the school year when a general (rather than individual) problem has been identified. For example, monthly reminders or 'flyers' can be sent home from school, informing and reminding families about detection through 'wet combing' and general grooming.
The power to exclude a pupil from school and the circumstances in which that power may be exercised are set out in regulation 4 of the Schools General (Scotland) Regulations 1975 as amended. The power to exclude rests with education authorities who are required to establish and operate local exclusion guidelines.
The 1975 Regulations state that education authorities shall not exclude a pupil from school unless certain specific circumstances prevail.
There are a number of statutory provisions concerned with exclusions, ensuring the cleanliness of pupils, and preventing the spread of disease among schools. Head lice infection is not considered to constitute a disease or a danger to health.
The Scottish Executive's view is that exclusion is a serious disciplinary measure that should only be used in appropriate circumstances as a last resort, and should not be used to manage head lice infection as a matter of course. Parents should also be advised that it is not necessary to keep children off school because they have head lice. Missing school means that pupils may miss out on learning, and it can be difficult for them to catch up. Exclusion risks stigmatisation and can have a serious impact on a child or young person's self-esteem. Children and young people may also feel discouraged and may, inadvertently, be disengaged from learning altogether.
Persistent or recurrent head lice infection
A distinction between re-infection and a continuing infection should be made. If a child still has head lice following full treatment, their parents should take them to a health professional to establish whether it is a re-infection, or if previous treatment has not been effective.
If insecticide lotions are not applied properly or the second application is not given, the treatment will not be effective. Similarly, the 'bug busting' approach will not be effective unless parents continue the process every 3 days for up to 3 weeks and have successfully removed all the head lice and eggs.
A major cause of concern for parents is re-infection of children who have been treated following contact with children who have not.
Families experiencing continuing or recurring head lice infection should be assisted and supported, as they would be if their child contracted any other infection. This should include co-ordinated and sustained support and help in the community (including the school) and from health professionals. Repeated head lice infection may be symptomatic of other family stresses or neglect.
If a child presents with consistent or repeated head lice infection despite information and support to parents to treat the recurring head lice infection, health professionals and school staff should jointly consider what action to take next. If the family is experiencing difficulties which prevent the parents from treating head lice infection effectively, they may need additional or special help from the health service or local authority social work services at home. The Children (Scotland) Act 1995 requires the local authority to safeguard and promote the welfare of children in need, with the assistance of other agencies, including health services.
Any decisions taken should have the child's welfare as the paramount consideration.
Under section 58 of the Education (Scotland) Act 1980 it is an offence, ultimately punishable by fines or imprisonment, for a parent to send a pupil to school with recurrent infections due to their own neglect. However, health and education professionals must approach parents who neglect to treat their children from a position of support and encouragement, rather than with threats of punishment.
NHS Board and Local Authority policies
In order to promote consistent and effective management of head lice infection across Scotland, it is recommended that NHS Boards, in partnership with Local Authorities, should establish a clear policy document on the management of head lice infection that is consistent with the advice in this guidance. The policy should include clear statements on
prescription of insecticides and bug busting kits;
advice and support for parents; and
advice/action to support families affected by persistent or recurrent infection.
Note should be taken of the recommendation in the Stafford Report that the term "infection" should be used rather than "infestation" in all head lice policy and information materials, to address the pervasive problem of stigma.
The NHS Board's policy document should be disseminated to all health professionals who may have contact with children or who may be approached by parents or schools for advice. Boards should also liaise with local authorities to ensure that policies are communicated effectively to staff in the full range of child care and education settings.
The Stafford Group produced a series of guidance notes for health and education professionals; separate notes and guidance were produced for primary care staff, pharmacists, school nurses and head teachers. These are attached as annexes and have been updated to reflect the Scottish position and the advice given in the guidance.
It is crucial that all agencies take responsibility for giving accurate, consistent and impartial information and advice.