 Welcome to today's Wednesday webinar entitled, 11 Myths About Headlights. My name is Jill Bates and I am the ESU 8 Nursing Coordinator. Thanks for joining me as I review some of the most common misconceptions about headlights and explain current recommendations regarding headlights in schools. The information for this webinar is based on the following resources. An article from the September-October issue of Pediatric Nursing entitled Demystifying Pediculosis School Nurses Taking the Lead, as well as supporting information from the Centers of Disease Control and the National Association of School Nurses. Headlights. For the school community, headlights infestations are a time-consuming, seemingly never-ending problem. I'm very fortunate to get to work with a great group of ESU 8 school nurses and headlights is one of the most common topics of discussion whenever we get together. And this itchy topic is one that causes most school administrators and teachers to cringe and to scratch their heads. In fact, there is evidence that headlights have been infesting humans for thousands of years. Headlights have been found on mummies, and ancient nitcombs like this one have been discovered in their tombs. It's been said that Cleopatra had very elaborate nitcombs, so even back then, headlights knew no class barriers. So to start, let's review a few basic definitions. A louse is a small insect that lives on the scalp, and the term lice refers to more than one louse. When a louse is present in someone's hair, they are said to have an infestation or a case of pediculosis. The headlice eggs, whether dead or alive, are called nits. And finally, just for clarification, headlice are parasites, which means that they live off human blood. Headlice feed on this blood several times a day, and therefore have to live very close to the scalp. So what do headlice look like? According to the CDC, you can see on this slide, there are three forms of the lice. Here is a nit, here is a very small nymph, and here are the adults. Nits are lice eggs that are laid by the adult female headlouse at the base of the hair shaft nearest the scalp. Nits are firmly attached to the hair, they're oval-shaped, and about the size of a knot and thread. They're usually yellow or white, although wide nits sometimes appear to be the same color as the hair of the infested person. They can be difficult to see and are often confused with dandruff, scabs, or hairspray droplets. Headlice usually take about eight to nine days to hatch, so they go from the egg and they hatch into a nymph. Nits that are likely to hatch are usually located no more than a fourth of an inch from the base of the hair. Nits located a half an inch from the base of the hair shaft may very well be already hatched, or they might be empty nits. This is really difficult to distinguish with just the naked eye. A nymph is an immature louse that is hatched from the nymph. It's smaller than an adult, but it looks very similar. And to live, a nymph must feed on blood and matures into an adult about nine to twelve days after hatching. The fully grown adult louse is about the size of a sesame seed, has six legs and is tanned to grayish white in color. Adult headlice may look darker in persons with dark hair than in persons with light hair. An adult headlouse can live about 30 days on a person's head, feeding on their blood. But if it falls off a person's head, it will die within one to two days. Adult female lice shown here are usually larger than males, and they can lay about six eggs each day. This slide shows the progression from a newly hatched nymph increasing in size until the adult male and adult female. So what traditionally happens in schools in the past when there has been a suspected case of headlice? Let's consider this scenario. We have a second grade student named Nathan, and he's been sent to this school nurse's office because a teacher saw him frequently scratching his head, especially behind his ears and at the nape of his neck. So the nurse performs a head check, and while doing so she identifies some tiny white objects on his hair about an inch from the scalp. She doesn't see any evidence of nits closer to the scalp, nor does she find any live lice. But per school policy she immediately calls the parents and requests they come to pick him up. So they come to school, his belongings are brought to the office, and when the parents arrive the nurse describes the treatment program and also explains that Nathan might have lice, he probably needs to be treated, and then she explains that the district has a no-knit policy which means that all nits must be removed from his hair before he can return to school. She also describes a treatment program that includes washing all the linen in the house, washing all of his clothing, putting all items that cannot be washed such as stuffed animals into a plastic bag for ten days, and vacuuming all hard and soft household surfaces. After Nathan leaves she performs head checks on all the rest of the students in the classroom and then sends a letter home with those students letting the parents know that there is a case of head lice in that room. Once school is dismissed the teacher asks the nurse to check her hair as well and to sanitize all the headphones in the classroom. That's what we have traditionally seen in schools. The problem with that scenario is that not one of the school nurses' interventions is evidence-based current best practice. Unfortunately this scenario is still all too common so let's take a quick look at some of the recommended best practices that are current and up-to-date. Myth number one, lice are easy to get. We all know that they're easily passed from person to person and they can jump or fly. False. In actuality lice cannot jump, fly, or even crawl long distances. Their pincher-like grasping structures allow them to hold onto the hair shaft and even bathing, shampooing, or daily hair brushing cannot easily dislodge them. And if you look here you can see those pinchers right here. They're not easily dislodged from the hair. However there is a very small theoretical possibility that hair care items may assist in the transmission of lice. So it is prudent to recommend that students not share combs, brushes, or other hair items. Lice are most commonly spread by direct contact with the hair of an infested person. Spread by contact with inanimate objects such as hats, scarves, or coats may occur, but it's very, very uncommon. Slick helmets like those for baseball, football, or bicycling really pose very little risk because there's no place for the head lice to grasp. Sharing beds, however, is noted to be a significant risk factor for transmission because of the extended time that heads are close together. Myth number two, you can get lice from pets. No, human lice live only on humans. Myth number three, you must clean your house from top to bottom because those lice could be anywhere. Now remember, a louse is a parasite and its entire existence is dependent upon human blood. Without a human host, lice typically die within one to two days. Eggs may remain viable a little bit longer, but as soon as that nymph hatches, it also must feed on human blood or it will die within a few hours. If a child is determined to have a head lice infestation, focus on cleaning items such as clothing, bed linens, furniture, car seats, carpeting, or rugs, or other fabric covered items that have been in contact with the child's head in the past one to two days. Although rarely necessary, some experts do still recommend that items that may be contaminated by an infested person and that cannot be laundered or dry cleaned should be sealed in plastic bags and stored for up to two weeks to kill any lice that could be present. No-side spray is not necessary and should never be used because it provides unnecessary exposure and it can be dangerous to infants. The American Academy of Pediatrics finds no benefit in over-the-top cleaning measures. Myth number four, head lice seem to affect those with poor hygiene or those from families with low income. Truthfully, head lice often infest people with good hygiene and grooming habits. Regular hair hygiene won't eliminate or prevent head lice, but it may remove lice that are dead or dying. On the other hand, however, there is some evidence that more lice will be found on a head that is shampooed or brushed less often. All socioeconomic groups are affected, even the Ben Affleck Jennifer Garner household, and infestations are seen throughout the world. In the U.S., children in preschool and the primary grades are affected more often, as are their caregivers and housemates, primarily due to the opportunity for close, head-to-head contact. Myth number five, knits indicate an active case of head lice. Three stages of the louse life cycle, remember, knit, nymph, and adults last approximately 45 days, and only the presence of a live louse is considered the gold standard for an active infestation, not the mere presence of knits. Remember, viable or live knits are usually found no more than one-fourth to one-half inch from the scalp. If no live lice are seen and the only knits found are more than a fourth to a half an inch from the scalp, the infestation is probably old, no longer active, and does not need to be treated. Myth number six, no knit policies in schools reduce cases of head lice. I anticipate that this stance, taken by the CDC, the American Academy of Pediatrics and the National Association of School Nurses, may be the most controversial part of this webinar. All three organizations believe that no knit policies should be eliminated because there is no evidence that these policies reduce the transmission of head lice in schools. However, significant evidence does indicate that no knit policies increase absenteeism, shame, stigma, and unnecessary treatment. In Nebraska, schools fall under the Department of Health and Human Services, rule 173, a regulation that addresses the control of communicable diseases. These school health requirements specifically outline control measures in the school setting, including head lice. You can read here that the control measure states, knits are not a cause for school exclusion. Parents of students with live lice are to be notified and as a child treated prior to return to school. Only persons with active infestation need be treated. Avoid head-to-head contact and no exclusion of contacts. However, eliminating no knit policies does not mean eliminating a need to treat the infestation. Treatment remains a very high priority. Although not dangerous, head lice infestations may be uncomfortable and they should be managed and treated. Myth number seven, schools are a common place for head lice transmission. Surprisingly, schools rarely provide an opportunity for close head-to-head contact, except for very young children such as preschoolers or lower elementary students. Head lice are most often a community health issue that's brought into the school setting. Schools often see a spike in cases after a break in the school year, such as Christmas vacation or after summer vacation. This is often falsely attributed to a return to the school environment, but it's actually due to being in the community for an extended period of time and having opportunities for sleepovers or going to camp or visiting relatives. The school, rather than being the cause of the infestation, is the location of its identification. Evidence indicates that at any one time, one to ten percent of U.S. children in kindergarten through fourth grade have head lice, and it's estimated that of these children, only ten percent were transmitted at school. It really does not make sense to exclude a child when the likelihood of transmission in school is far less than that of the common cold. Myth number eight, classroom head checks can limit the spread of head lice. Again, it's the position of the National Association of School Nurses, the CDC, and the American Academy of Pediatrics, that most school screenings, whether they're routine or after an identified classroom case, are not productive, they're not cost-effective, and they can be wasteful of educational time. However, it is very, very important to check the student's close contacts, including all household members, those who have recently spent the night, family members who travel between households and blended families, and children who spend large amounts of time together outside of school, such as at daycare or with babysitters or at a camp. Full class screenings are still advised, though, for preschool and lower elementary classrooms where children sit near each other and play together frequently. Myth number nine, school should send home a letter when a case of head lice is identified. Now again, there's no evidence to support the claim that these letters prevent head lice transmission, and they may in fact be a violation of privacy and confidentiality. There is no known method to prevent head lice other than by shaving the hair on the scalp. Sending a letter home may, as it should, cause parents to check their children. However, doing so may create a false sense of security if they don't find anything, or it might cause some parents to treat unnecessarily. These letters often result in panic and emotional distress among caregivers, and they also help to perpetuate that myth that lice are transmitted in schools. However, some schools continue to send these alert letters because while they understand that head lice are not a public health risk, they are concerned about a public relations backlash from the community. Parents often insist that they have a right to know. However, they truly do not have a legal right to such information. And even though specific student names are not shared, the parents need to only ask their own child who went home from school today, and the breach of confidentiality has occurred. Parents and guardians are better served through regularly scheduled head lice information letters sent several times a year, most appropriately at times when children are returning after breaks. Suggested contents of these letters might include reminders to regularly check their children's hair, instructions on how to check, or treatment instructions. Myth number 10, everyone in a home should be treated. No, treatment should be initiated only for those with clear evidence of head lice, and they should all be treated at the same time. Otherwise, they could reinfest each other. However, all family members should be examined. Prophylactic treatment is unnecessary, time-consuming, and expensive. Finally, myth number 11, pedicula lice are dangerous, and they should be avoided. Besides, head lice are resistant to them anyway. Now, over-the-counter preparations remain the first line choice for treatment, and they also remain very effective if they're used properly, and the key word is, properly. They are relatively inexpensive, have extremely low toxicity to humans, while being neurotoxic to lice. Most of these medications kill live lice, but not the unhatched eggs. So a second treatment on day nine is often recommended, and the timing of the second treatment is very, very important. It needs to be after those initial eggs have hatched on day nine. Experts recommend referral to a healthcare provider after two over-the-counter treatment failures. Resistance is often branded as the cause of treatment failure. However, the CDC has identified several common reasons why treatment for head lice may sometimes fail. One, misdiagnosis. Two, using the treatment after a conditioning shampoo or hair conditioner has been applied. Conditioners act as a barrier that keeps the head lice treatment medicine from actually working. Three, not carefully following the instructions for treatment. Remember, some examples of this include not applying a second treatment if instructed to do so or retreating too soon after the first treatment before all the nits are hatched. Then it's ineffective, and so it's very important to follow the instructions. Number four, a reinfestation. The person was treated successfully. The lice were eliminated, but then they became reinvested because they got him from another infested person. Or occasionally there will be resistance, and this is something that a healthcare provider can help with. If the treatment does not kill the head lice, a healthcare provider can help determine if the product was used correctly, or they may recommend a completely different product. There's a lot of information out about home or national natural remedies like olive oil, tea tree oil, lavender oil, or mayonnaise. These are not regulated by the FDA. They have not been shown to be effective in any known double-blind studies, and therefore they're not recommended. If you would like additional resources that are reputable and reliable, please check out some of these sites. I especially like the information that is included on the Lancaster County UNL Extension website. This site includes an eight minute video entitled, Removing Head Lice Safely that gives step-by-step instructions on proper calming. I'll remember next week's Wednesday webinar will be presented by Natalie Parsley, ESU 8 Vision Teacher. It's entitled, Vision Impairments, What Are the Signs, and What Does a Teacher of the Visually Impaired Do? Please join Natalie if you're interested in learning more. Oh, we're out of time, so if you have any questions, please email me or give me a call. And remember that you can always access the recording of any ESU 8 Wednesday webinar by checking out the Wednesday webinar link on our ESU 8 homepage. Thanks so much for joining me and have a great rest of the week.