The Dreaded Diagnosis: Lice
As Chris, RN, took report for the day shift in the Pediatrics ICU, she overheard the dreaded words: lice. Tuning in, she paid attention as the staff discussed a 3 year old being treated for RSV who was improving but began vigorously scratching her head, to the point of leaving marks along her hairline and around the base of her neck. When the night nurse leaned in to examine her head, she noticed the lice moving. Drawing back, she motioned for the doctor who was nearby to step over. Together, they confirmed the unpleasant diagnosis: lice infestation.
Pediculous humanous capitis or head lice, are “ 2.1–3.3 mm in length. Head lice infest the head and neck and attach their eggs to the base of the hair shaft. Lice move by crawling; they cannot hop or fly.” - Parasites - Lice - CDC They feed on human blood and lay their eggs, called nits.
Who Gets Lice?
Almost on cue, all the staff felt their scalps crawling and began to have the urge to scratch. While lice are not a health hazard, per se, there is a strong stigma attached to having lice. The truth is, however, that the infestation affects all socioeconomic levels and all ages but primarily children in crowded conditions, especially Caucasians. “Head lice are more common in girls than in boys and are more common in Caucasians than in African-Americans. Anyone can get head lice. It is not a sign that a person is unclean.” - Head Lice - Cleveland Clinic
Chris said, “It is unfair to equate lice with poor hygiene. At times, they do go together as families who live in conditions where there is no running water or access to lice treatment, can have significant problems. These issues will often become apparent at admission during the history-taking process. Sometimes we see red flags that alert us to check. But sometimes, we miss the infestation as we are busy prioritizing other needs that are more life-critical and it is only after they are stabilized and doing better that we detect lice. Lice is an equal opportunity infestation.”
Chris elaborated that the detection of lice almost always fills everyone with dread because lice can be so hard to eradicate. It takes a concerted effort, treatment of the whole family, cleaning of all linens, car seats, upholstery—it’s a job!
How do you diagnose lice?
When people have lice, they usually scratch vigorously, so hard, in fact, that they sometimes have scratches along the hairline and around the ears and at the base of their necks, where the lice are most likely to take up residence. Children will employ a “two-handed scratch” where they get both hands up to their heads. Their hair will often be tangled and messy because of the scratching.
In the hospital, to diagnose it, you have to see a louse and have it confirmed by a second person, usually the doctor. Also, sometimes the nits, little white eggs that cling tightly to the hair shaft, are the first sign.
So what do nurses need to know?
And how do we best help ourselves and our patients?
Getting Rid of Lice
Getting rid of lice is not always easy. It requires dedication and persistence but it can be done. By encouraging our patients and their families in a straightforward, professional manner, we can maximize their confidence and their potential success.
Reading about it on the internet can sometimes raise unreasonable fears of “super lice” and persistent infestations. It might be helpful for us to give our patients guidelines from trusted sources such as the CDC and Cleveland Clinic. The CDC.gov site has thorough and practical recommendations.
Treatment with lice/egg killing pyrethrins is the beginning of the process. Some pediculocides are ovicidal and some are not. Sold over the counter in kits, the shampoos are generally effective in eliminating the lice. Following up with dedicated hair combing for nits is critical. Otherwise, the eggs will hatch and the infestation will return. Some sources advise treatment of the head, treatment of the environment, daily nit removal and then a repeat treatment in 7-10 days with continued combing after that if nits are found.
If treatment with over the counter kits is not effective, patients can follow up by contacting their primary care provider for perscriptions which go by brand names such as Sklice, Ulesfia, Ovide and Natroba.
Practical tips on combing it out:
Wearing gloves, brush the hair first to get the snarls out (then clean the brush).
Treat the hair as per directions on the box.
Divide the hair into very small segments.
Using a nit comb from kit, comb through thoroughly, using detangle spray. (Sometimes provided in kit)
After each pass of the comb, wipe it off on a paper towel or toilet paper and discard into a prepared trash bag.
Wash all combs, brushes, towels, hats, etc. after each treatment.
After initial linen and pillow wash, consider changing pillowcases and washing favorite blankets or stuffed animals daily throughout duration of the process.
Internet solutions are plentiful. Some of them have merit such as the “goop” that helps make the hair slick and easier to comb through after the initial treatment. Additionally, parents can find community and support online, when sometimes talking with family or other parents is hard.
The usual recommendations involve keeping hair pulled up and back off the face, not sharing brushes, combs or hats and prompt treatment when problems are discovered.
Lice treatments can be expensive for parents on a limited budget. It is important that we be sensitive to this and try to help parents find funding for treatment kits as well as for the laundry a lice infestation generates. Working together in hospitals, schools and daycares, we can help promote prompt treatment and fewer cases of head lice.
Are you itching yet????