Head Lice Etiquette: All The Questions You’re Afraid To Ask — Part 1

Nit-picking

I was a head lice virgin. Every once in a while, our elementary school would send home a flyer about a case of lice, and I would casually glance over my children’s silky blond heads, imagining an insect the size of a mosquito. No, nothing.

Then, just after winter vacation, I noticed that my daughter seemed to be scratching above and behind her ears a lot. For all my ignorance, I knew that was a telltale sign. I asked Leeza, our omniscient former nanny, to inspect. In a previous life, she was the deputy director of a summer camp in Ukraine, where she became all too well acquainted with lice — and where they were treated the nasty old-fashioned way, with kerosene (don’t try that at home) and head-shaving. And yes, this was another case.

My heart dropped. My mind spun. I ran to the drugstore, ransacked Google and obsessively begged advice from friends and virtual strangers. Turns out lice infestations are a bit like miscarriages — when you speak up, almost everyone has a story. And here’s the good news: If you have to catch head lice, Boston is a prime place to do it, because we’re extraordinarily rich in expertise. We have the National Pediculosis Association, a 28-year-old non-profit that aims to educate and prevent. We have Richard J. Pollack, PhD, an entomologist and louse expert affiliated with Harvard and Boston Universities who has researched and taught about such pests for decades. We have the Massachusetts School Nurse Organization, led by president Mimi Stamer, PNP. And we have “The Nit-Picker, Inc.,” a Needham-based lice and nit removal service that is ten years old, makes house calls and has helped more than 5,000 clients. (Including my children. Best birthday present I ever got.)

I climbed a steep learning curve on head lice, from their life cycles to the gamut of remedies, and am thrilled to report that my children now appear to be lice-free — at least, for now. And I’ve calmed down quite a bit, accepting head lice as a problem that must be painstakingly dealt with — one friend calls it “The Olympics of Motherhood” — but not a threat.

Next week, I’ll get into the controversial lice-information landscape and the latest news on remedies. But first, I wanted to ask our experts the questions that are never addressed in the shampoo instructions or the doctor’s office. When it comes to head lice, how are we supposed to behave with each other? Many parents seem to observe a sort of lice omerta. Biblical feuds flare in families over lice. Friendships break up. Communities fracture into factions. What did you know and when did you know it? Perhaps we could all use a head lice code of conduct. Here’s an initial attempt, and readers, I implore you to contribute your feedback and ask your own questions. We’ll be running three or four questions a day all week, and then will put it all together in one overarching post, which also discussed on Radio Boston.

Combing out lice and nits with a special comb

(Full disclosures: I should note that Richard Pollack and the National Pediculosis Association are longtime adversaries. On the head-lice spectrum, Richard is on the end that sees lice as a natural part of human life for millennia, and the shampoos available as generally good solutions. The NPA, led by Deborah Altschuler, sees head lice as a significant public health problem and is deeply concerned about the pesticides in the shampoos; it advocates a no-nit policy. Richard operates a business, IdentifyUS LLC, that offers guidance and insect identification services. He consults to shampoo makers but has no financial interest in their products. The NPA, a volunteer nonprofit, sells specially developed nit combs. And of course, Helen Hadley owns The Nit-Picker, Inc., a private lice and nit removal service, and Mimi Stamer represents the MSNO school nurse constituency.)

1. I find out that my child has lice. I’m panicked and embarrassed. Do I have to tell anyone?

Mimi Stamer, Massachusetts School Nurse Organization:

If you learn that your child has lice, you need to first take a deep breath, relax, and try to remain calm…. remembering that lice is a common childhood condition and it is NOT life-threatening.
You need to inform your child’s school nurse, as she will take the responsibility for the school management and provide you with information and advice for treating the lice, removing nits, and preventing re-occurence. She will also discuss with you any applicable school policy or protocol. You should consult your child’s primary care provider regarding a recommended over-the-counter ovicide product for your child to treat the lice, and ask for guidance if your child has any other health conditions or allergies that may need special consideration. You should contact your child’s close friends, relatives, and contacts so those children may be checked and monitored for live lice and nits. You should also check your other children and spouse/partner or other adults in the household.

Deborah Altschuler, National Pediculosis Association:

The short answer is yes.  Regardless of assurances otherwise, pediculosis (infestation with head lice) is a communicable disease that represents a public health problem for children and entire communities.  Children are too often unnecessarily exposed to pesticides because of head lice.  A community problem requires community cooperation.  Embarrassment indicates a situation where parents may be burdened because they have not been provided with knowledge, accurate resources and support.  Without preparation it is natural for people to fear the response they may get when they talk about head lice. This is another good reason to set the highest possible standards in advance of outbreaks.

Richard Pollack, PhD, IdentifyUS

No. There neither is a legal requirement nor would it necessarily be justified to disclose this condition. Why not divulge the information?  In many cases, the presumed ‘infestation’ is imagined rather than real. So, telling others may simply be spreading misinformation.  OK, but if you’ve found a bona fide louse, and have not removed it or treated appropriately, then make a risk assessment.  Because head lice are shared mainly by direct head-to-head contact, the chance of transmitting a louse is vanishingly tiny if your child is not likely to have such contact.  Consider also whether the information will cause the recipient to panic.  Reassess your own mindset.  Why would or should you be embarrassed or upset if your child is ‘with lice’?  This should not be a shameful event, either for parent or child.  Realize that head lice are the most minor and insignificant of childhood infections or infestations, and that having head lice is often a sign of a social child.

Helen Hadley, The Nit-Picker:I look at being panicked about head lice and being embarrassed about them as separate phenomena.

A panicked person needs access to accurate and useful information about head lice that will help them chart a course of action. The information should include the pros and cons of the many treatment options available (most of which, unfortunately, are ineffective). By my assessment, 85% to 90% of the information about head lice on the Internet is inaccurate and very likely to further aggravate a panicked person who ventures into the morass of conflicting information. Knowledge empowers people to take action, and taking action reduces the panic inherent in the feelings of helplessness that confront many people who are facing an infestation for the first time.

Hopefully, being embarrassed about lice does not deter a person from taking the high road and informing others who they may have inadvertently exposed to lice. Informing the school nurse is also important. Many people do not understand that you have given them a gift when you inform them that you may have exposed them to lice and, of course, many will not thank you. Hopefully you will know within yourself that you have done the right thing.

2. I instantly follow medical instructions and use the shampoo that is supposed to kill live lice, and begin combing to remove nits. Do I still have to tell anyone?

Mimi Stamer, Massachusetts School Nurse Organization:

Yes — as answered in question #1, informing other adults of children who have close contact (neighbors, sleepover friends, sports team friends, classmates, scouts etc.) will promote their early identification and treatment of lice too, and prevent the continued re-infestation of your own child and others.

Deborah Altschuler, National Pediculosis Association:

Product claims can be misleading. We are unaware of any chemical treatment that is 100% safe or effective against lice and their eggs (nits). “Begin” combing is a step in the right direction but “if you don’t get them all out – you’ve still got them.” Pediculosis is a communicable disease. Parents appreciate the earliest possible notice of an outbreak so they can be especially diligent in checking their families. Otherwise they understandably may feel disappointed and angry. We must all be sensitive to the reality that many children have already been exposed to pesticides for earlier head lice infestations multiple times. The earliest possible notice of an outbreak may help other parents avoid future infestations and the risks of additional chemical exposures. The NPA’s “No Nit Policy” is here.

Richard Pollack, PhD, IdentifyUS

If you believe you’ve taken reasonable steps to abate the infestation, then why act as if the problem still exists? Doing so risks alienating your child from you and from his/her friends.

Helen Hadley, The Nit-Picker:

Unfortunately, the over-the-counter shampoos that were once effective are no longer reliable. They continue to give many people a false sense of security regarding successful treatment. Twenty years ago neither Rid nor Nix killed the bugs when my children and I had lice and the pharmacist, who I hoped would refund my money, explained that the bugs were building a resistance to permethrin (the active ingredient in Rid and Nix) and that each year going forward the efficacy of Rid and Nix would continue to diminish. Combing offers greater benefit at this time, in my opinion, provided an effective, high quality comb is used—most are not. Personally, I consider it essential to continue daily checks and combing for a minimum of two weeks after the last bug has been seen. During this time I consider it a courtesy to let family and friends make their own decision about having contact with your family.

3. I’ve seen no new live lice or nits for several days. Now do I have to tell anyone?

Mimi Stamer, Massachusetts School Nurse Organization:

If you haven’t told anyone that your child was recently treated for lice, you need to do so because it is likely that other children may have live lice hatching and the spread may continue if those children aren’t treated too. Your child and your children’s close contacts should have their heads checked weekly per routine monitoring.

Deborah Altschuler, National Pediculosis Association:

Visualizing lice and nits is not necessarily the criteria for being a proactive voice. Encouraging others to screen their children is an ongoing measure that will help protect your family as well as theirs. Children are vulnerable to acquiring head lice over and over again. Telling others that you are screening regularly may help raise the community standard by reminding others to do the same.

Richard Pollack, PhD, IdentifyUS

Only if you wish to proclaim to the world that you have (apparently) vanquished your enemy.

Helen Hadley, The Nit-Picker:

If no new lice have been seen for at least 10 days, and head checks have been done daily, I do not consider it necessary to tell anyone, but I do consider it necessary to continue checking daily until two weeks have passed of finding no bugs at all.

4. My children have lice, and suddenly I’m noticing every itch on my head. Yet I don’t seem to have them — or at least, not yet. How do I behave with co-workers, friends and others I may come in contact with?

Mimi Stamer, Massachusetts School Nurse Organization:

As adults we should be able to minimize our spread of lice (and germs) through behavior like not sharing combs/brushes or hats, clipping long hair up, and not engaging in head-to-head contact if we suspect we may have lice. If your head persists with itching, you should comb with a fine tooth metal comb to capture any lice and also have an adult check your head for nits. You do not need to treat yourself preventatively. Some treatments cause itching due to irritation, dry scalps, and other sensitivity. The natural response to the topic of lice is often to make adults start “scratching.”

Deborah Altschuler, National Pediculosis Association:

This question is about the anxiety that comes with not knowing what to do. It is also a reminder to screen yourself regularly as well. It is also an opportunity to ask someone for help if you need it, and some people do. An effective lice and nit removal comb can allow you to independently screen yourself, document an infestation if you have acquired one – but also be assured when you haven’t! When you have the proper knowledge and tools you can avoid unnecessary worry and be confident when you are lice- and nit-free.

Richard Pollack, PhD, IdentifyUS

Considering head lice to be the cause of every little itch for the rest of your life is, sadly, a bit of psychological baggage that burdens many folks. Everyone’s scalp itches many times a day, whether or not head lice are, or were ever, present. If one suspects that a louse may be present, it is reasonable to check. Absent a louse, the itching may simply result from other causes. If the itching causes distress, it is time to consult with your physician to rule in (or out) other causes. Sharing your suspicion with coworkers and others may cause them to shun you.

Helen Hadley, The Nit-Picker:

A person can check themselves for lice and nits by combing with a good nit comb each day and checking to see if eggs or bugs are getting caught in the tines. If nothing is coming out with the combing, there’s no reason to tell co-workers anything.
In my experience, 70% of mothers whose children are nine years old or younger also have head lice. There is a direct correlation between the age of the child and the likelihood that the mother will also have lice. To the surprise of many, we have occasionally treated a mother whose children did not have lice.

Part Two, Fear of Reinfestatation, and more is here.

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