Head Lice: Management of Infestations in Children

Educational Objectives

The goal of this program is to improve the management of head lice infestations in children. After hearing and assimilating this program, the clinician will be better able to:

1. Optimize the management of head lice infestations in children.

Summary

Head lice (Pediculus capitis): commonly infests children in childcare, preschool, and grade school because of increased head-to-head contact; presence of head lice is not indicative of poor hygiene; in the United States, lice infestation is more common in Caucasian persons compared with African American persons; conversely, in Africa, they are more prevalent among African persons than White persons; they do not transmit diseases; these insects rely on the scalp’s heat and frequent blood meals for survival; if they fall off onto non-warm surfaces (eg, a hat), they become incompetent and are unlikely to be transmitted to another person

Clinical manifestations: most children with head lice are asymptomatic; however, some individuals may report a crawling sensation on their heads

Medical complications: though medical complications are minimal, social implications are significant; the resulting consequences include time lost from school and work, expenses associated with treatment, psychological distress due to perceived uncleanliness, and disruptions in family dynamics; visible nits are typically empty cases and pose no actual significance, as the live organisms are closer to the scalp and are often the color of the hair

Diagnosis: identification of head lice requires observing live insects; however, lice avoid light, making it challenging to spot them as they move away from illuminated areas; many clinicians attempt to diagnose lice based on the presence of nits, but this method is prone to overdiagnosis

Treatment

Permethrin: the drug of choice is permethrin 1% lotion; however, resistance to this treatment is common; if it fails, alternatives include permethrin-based products derived from chrysanthemums (available over the counter), with the caveat that individuals with ragweed allergy should avoid them; retreatment may be necessary

Malathion: a more effective option but requires a prescription; its flammability necessitates caution, ensuring no smoking or open flames around the child; reapply only if live lice are observed

Spinosad: a neurotoxin for lice but safe for children; involves a 10-min application on dry hair; contains benzyl alcohol, making it unsuitable for children <6 mo; relatively expensive and requires reapplication only if live lice persist

Abametapir: a prescription lotion; inhibits metalloproteinases; also contains benzyl alcohol and is not recommended for children <6 mo; costly

Ivermectin: lotion (not oral) is approved by the US Food and Drug Administration, though it is not ovicidal; a single application is effective but can be expensive; oral ivermectin, though not yet approved, is effective, but caution is advised in children weighing <15 kg because of safety concerns

Lindane: discontinued due to neurotoxic effects

Smothering agents: mayonnaise and petroleum jelly are sometimes employed to combat head lice; while some claim occasional success, it requires leaving them on overnight because of the lice’s infrequent breathing; not recommended as a primary therapy

Things to avoid: avoid using kerosene as it is highly flammable and ineffective; head shaving works but is considered aggressive and unnecessary; insecticide sprays should be avoided as they pose inhalation risks and can be toxic to the child

Nit removal: involves removing empty egg cases firmly attached to the hair; fine-tooth combs are commonly used for this task; nitpicking may be considered by many as a waste of time and energy; contrary to popular belief, no-nit policies in schools are deemed ineffective, leading to unnecessary panic; the manual removal of nits is suggested after successful pediculicide treatment to reduce diagnostic confusion, self-reinfestation risk, and social stigmatization; however, it may not significantly alter outcomes

Readings

Babazadeh T, Chollou KM, Abedi-Nerbin S, et al. Head lice infestation and the role of some cognitive-behavioral factors in its spread and prevention among adolescent girls: A cross-sectional study in Northwest Iran. Health Sci Rep. 2023;6(11):e1679. Published 2023 Nov 1. doi:10.1002/hsr2.1679; Jahangiri F. Case report: a new method for treatment of permethrin - resistant head lice. Clin Case Rep. 2017;5(5):601-604. Published 2017 Mar 17. doi:10.1002/ccr3.899; Leung AKC, Lam JM, Leong KF, et al. Paediatrics: how to manage pediculosis capitis. Drugs Context. 2022;11:2021-11-3. Published 2022 Mar 14. doi:10.7573/dic.2021-11-3; Mumcuoglu KY, Pollack RJ, Reed DL, et al. International recommendations for an effective control of head louse infestations. Int J Dermatol. 2021;60(3):272-280. doi:10.1111/ijd.15096; Ryoo S, Hong S, Chang T, et al. Prevalence of head louse infestation among primary schoolchildren in the Republic of Korea: nationwide observation of trends in 2011-2019. Parasites Hosts Dis. 2023;61(1):53-59. doi:10.3347/PHD.22134.

Disclosures

For this program, the speakers and members of the planning committee reported nothing relevant to disclose. Dr. Fisher’s lecture includes information related to the off-label or investigational use of a product, therapy, or device.

Acknowledgements

Dr. Fisher was recorded at the Aloha Update: Pediatrics 2023, held September 30 to October 6, 2023, on Kauai, HI, and presented by Children’s Hospital Los Angeles Medical Group. For information on upcoming CME activities from this presenter, please visit https://www.chla.org/chla-medical-group/cme-conferences. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

PD701403

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.