I’m not trying to ruin your holidays (or your appetite). I really couldn’t and wouldn’t make this stuff up. But yes, we have had a lice infestation for the holidays. Last Thursday we flew to California to be with family for Christmas. Before that, I was in the midst of typical holiday madness, but I also felt this year, in particular, I’d managed not to get stressed. While in clinic on Wednesday, I made a conscious decision that I wasn’t going to stress about the to-do list awaiting me at home. The perspective I get while seeing patients often helps me frame my own stress. Compared to a broken arm or a bout of RSV, a packing list is really nothing. My husband was on call on Wednesday, so when I returned home from clinic around 6:30pm, the to-do list was mine alone. I needed to pack the family for the holiday, finish off some writing, wrap some gifts, and find something for dinner while completing the Christmas cards. I had about 12 hours before we needed to leave for the airport. But this is the life of nearly every parent at one time or another, particularly around the holidays. Then it hit.

Just before our nanny left, she mentioned F was complaining of an itchy scalp. The rest goes something like this:

Me: “Really? F, Lovie, come here, let me look at your head.” Pause. Gulp…….wait for it……..”You’ve got to be kidding me, lice for Christmas.”

F had lice. Yes, we’d received a letter the week prior that a “sibling” of one of the preschoolers had lice. The letter seriously sounded like the stories we hear from others about a “friend” with an STD or a “neighbor’s child” who bites. I figured one of the kids in school really did have lice and yes, the threat was there, but then blew it off and went on with life. New recommendations from the AAP this past fall encouraged schools not to send children home with lice or keep them away from school. I tend to agree with the recommendations as having families leave work and sending kids home seems an enormous interruption for a “non-health issue.” Maybe because of this, I was just about to have a front row seat in a major infestation.

Just then, the doorbell rang. Does this sound like a sitcom? One of our new neighbors was at the door, huge warm smile on her face. She was inviting us to a quick impromptu holiday party next door. Would I like to come? One of the older children had been offered up to watch the kids so I could head over and have a glass of wine. Pâté. Meet the neighbors, embrace the holidays.

I faked it; I smiled. I don’t eat pâté, but the wine sure sounded good. I didn’t tell this holiday-cheer-infused welcoming neighbor what was going on. I mean, when someone is standing in your home, for the first time, meeting your family and offering pâté and wine, do you tell them your child is covered in bugs?

I shut the door, said I would try to make it (that was the truth), and planned my attack.

First of all, I think (and have previously thought) lice can be difficult to diagnose. One study found that many presumed “lice” and “nits” submitted by physicians, nurses, teachers, and parents to a laboratory for identification were found to be artifacts such as dandruff, hairspray droplets, scabs, dirt, or other insects (eg, aphids). I’m a pediatrician and I doubted F’s diagnosis at first. To be honest, I didn’t get a lot of training on detecting lice in medical school or residency. It’s just simply not a medical issue, so families often don’t seek medical care. It may seem easy to find the bugs, but in a restless toddler or preschooler, it can be a feat. Lice also move quickly and avoid the light. Only after I got the uber-louse-killing-electric-comb thingy at the local pharmacy did I know for certain, in my heart of hearts, that yes, we were dealing with Christmas Lice.

Most of the statements in pediatric literature and in the typical teaching about lice sound something like this what the AAP says: “Head lice are not a health hazard or a sign of poor hygiene and, in contrast to body lice, are not responsible for the spread of any disease.” It doesn’t feel this way as a parent. Nope. Bugs crawling all over your son just doesn’t feel devoid of disease. Everything about it, at first, feels hazardous.

But let’s start with some facts to calm down. BTW, since starting reading this, have you started to scratch your head?

Head Lice Facts:

  • Head lice infestation is very common among children 3 to 12 years of age. A 1997 report estimated that approximately 6 to 12 million infestations occur each year in the United States (this may overestimate as the number comes from sales of pediculicides). The AAP says, “anecdotal reports from the 1990s estimated annual direct and indirect costs totaling $367 million, including remedies and other consumer costs, lost wages, and school system expenses.” So a fairly BIG deal, actually.
  • Head lice usually survive for less than 1 day away from the scalp at room temperature. Their eggs cannot hatch at room temperature lower than that near the scalp. So once they fall off a child’s head, lice pose very little threat. You don’t have to vacuum the carpet, sterilize the toys, wash the house top to bottom. The August 2010 AAP Head Lice Statement helps clarify. In 1 study, examination of carpets on 118 classroom floors found no lice despite more than 14,000 live lice found on the heads of 466 children using these classrooms. In a second study, live lice were found on only 4% of pillowcases used by infested volunteers. Thus, the AAP suggests major focus of control activities should be to reduce the number of lice on the head and to lessen the risks of head-to-head contact.
  • With a first case of head lice, itching may not develop for 4 to 6 weeks, because it takes that amount of time for sensitivity to result. The lice live near the scalp, feed of blood from little bites and hatch eggs. The casings of the eggs (nits) are often the easiest thing to see. Nits in some writing refers to the eggs, and in some just the casings of the egg.
  • Lice are not a hygiene issue. (I’m not just saying this as I out my son, really). Studies find that contracting lice has nothing to do with bathing standards or socioeconomic level. Translation: anyone, even those with pristine bathing routines and immaculate homes (who are those people?), can get lice!
  • Lice spread by crawling (they can’t hop or fly). They move from person to person by direct contact. Believe it or not, it’s rare for lice to spread via a brush, comb, or shared hat.

Treatment For Head Lice:

  • Electric combs: This is what I started with first. I went to my local drug store (circa 6:45pm) and talked with the head pharmacist. The pharmacist recommended the comb. The comb claims to kill both lice and eggs(nits) with no toxic exposure. The only precaution on the box was to avoid use in children with epilepsy or pacemakers. At home, (see photo) within seconds I heard the comb’s buzz stop indicating a dead louse. Within the hour, I had 38 dead lice! I combed and re-combed for over an hour. After about 20 minutes with no positive results, I stopped my search. Satisfied and exhausted, I thought I had done it. Only issue is that because lice move rapidly and shy away from light, they may be moving about the scalp while you work. This made me a little crazy….I kept combing and re-combing and re-combing…and the result? On re-combing the following day, I found 2 more live lice! That’s when I decided to go for a pediculicide. We were already at the in-laws for the holiday, Santa was on his way, and I felt I had no choice…The bottom line, I think these combs can work well, but not 100% of the time. They are tedious and you’ll never know for certain each bug or egg is killed because lice can move during treatment. If you chose to use one, you’ll need to repeat your work daily for 7-14 days. A HUGE time commitment. I couldn’t find any good research studies and data on these combs. Further, the AAP states, “No randomized, case-controlled studies have been performed with either type of comb.”
  • Pediculicides: These are chemical treatments that kill both the lice and the eggs/nits. 1% permethrin lotion (i.e. Nix) is currently recommended as one of the drugs of choice for head lice in the US. It claims to kill lice and their eggs for 14 days. However because of silicon-based additives in most shampoos/conditioners that remain on the hair shaft, there is concern that the permethrin may not stick to the shaft of the hair well and allow for ongoing killing of eggs. Many experts recommend re-treatment at 7 days and then again at 13-15 days after the first dose. Read a summary of chemical treatment options.
  • Hot Air: A recenty study in Pediatrics found that using hot dryers, called “LouseBusters” for 30 minutes (think salon type hair-dryer-chairs) may be a great cure for lice. But where do we find those? They are rare and expensive machines. Until they are found more readily, it’s hard to know how effective and useful they are.
  • Benzyl Alcohol: FDA approved use of 5% Benzyl alcohol in 2009, The product is not neurotoxic and kills head lice by asphyxiation. Studies demonstrated that more than 75% of the subjects treated were free of lice 14 days after initial treatment. Not perfect, but not bad. It doesn’t kill the eggs so you HAVE to retreat at 7 and maybe 13-15 days, even if you’re a master with the nit comb. You need a prescription for this.
  • Lindane: I don’t recommend it as it is considered neurotoxic and there have been numerous reports of seizures after use. With all the other options out there, avoid it. I’d say it’s better to have bugs.

So what about Nit Picking?

Until now, I’d never understood the rationale for nit picking when pediculicides kill both the live lice and the eggs. You may not need to do the combing, but your freedom from the comb will depend on your decision to re-treat. Reality is, none of the pediculicides are perfectly 100% ovicidal (egg-killing). So, removal of nits (especially the ones within 1 cm of the scalp) after treatment with any product is recommended. Nit removal can be tedious and challenging (I’LL SAY!!!). However, combing every last centimeter of your child’s hair may be worth your while. The AAP states that studies have suggested that lice removed by combing and brushing are damaged and rarely survive. So at least you’ll add to your electric comb, permethrin, or benzyl alcohol efforts…

Many urban areas have hair salons and private business that specialize in removing lice–and most offer a guarantee. If you’re not up for the lice-zapping electric comb or the Permethrin shampoos and subsequent nit picking, you can hire this out. I’ve known other friends who have done this and were satisfied. Often they did this after a second case of lice or a recurrence.

Although the whole experience of using an electric comb, followed by drowning our heads of hair in Permethrin one day later wasn’t ideal, it did feel a bit like a rite of passage in parenting. In the end, lice didn’t feel like disease, just incredibly disgusting and disruptive.

My plan for the week: I’m going to use 5% Benzyl Alcohol as a follow-up treatment for my son at the 7 day mark. And then re-comb with my electric comb. Want this done for good…

  1. And you? Share your life lice story. I hear a lot about the huge cost of time and money in riding lice along with the recurrent infestations from many patients and friends.
  2. Fill us in–what is your secret–what worked for you?
  3. How do YOU feel about the new recommendations from the AAP about keeping kids in school with lice?

38 dead lice.