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Rapid Responses: Rapid Responses published:
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why does bug busting fail?
- Wendy M McLean (7 June 2003)
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Parents Know Best
- Deborah Z. Altschuler (8 June 2003)
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Hope and honour in head lice
- Joanna Ibarra (11 June 2003)
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Put 'Best Treatments' Under the Microscope!
- Carol Teasdale (12 June 2003)
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Re: Parents Know Best
- Sylva Dolenska (12 June 2003)
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Head lice: update on biology and control
- Anita M. Bailey, H. Phillip Petersen (12 June 2003)
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Another misapprehension
- Jo Ann Rosenfeld, 1132 Annapolis Rd, Odenton MD USA 21113 (12 June 2003)
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Re: Exclusion from schools and nurseries
- Theo Fenton (13 June 2003)
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Conditioner and comb works for us
- Karen M Dacy (21 June 2003)
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Wendy M McLean, retired home
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As someone who has found wet combing with conditioner by far the most effective method I wonder why this method is said to fail? The re- infestation problem mentioned by other respondents makes controlled trials difficult and I question whether there are valid studies of any method. Electric nit combs are satisfying for the patient but we have found the version used on dry hair misses hatchlings while the version used on both wet and dry hair is less effective than combing with tea tree conditioner. For long term success nothing beats identifying the source of reinfection. Preventive strategies need to place more emphasis on scratching not being a good diagnostic tool! Competing interests: None declared |
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Deborah Z. Altschuler, President 50 Kearney Road, Needham, MA 02494
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One could write a book on all that is wrong or blatantly missing from this BMJ article. What is right however, is that parents do not need journal articles to know that they prefer safer treatment choices than pesticides, and are demonstrating their good judgement by refusing to accept prescriptions for malathion or lindane and choosing not to use lice pesticides in general. Sales of pediculicide agents continue on a steady annual decline. Congratulations to the parents and their children. "Because it's not about lice, it's about kids." Deborah Z. Altschuler President National Pediculosis Association www.headlice.org Competing interests: I am President of the National Pediculosis Association. www.headlice.org |
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Joanna Ibarra, Programme Co-ordinator Community Hygiene Concern, Manor Gardens Centre, 6-9 Manor Gardens, London N7 6LA
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Dear Editor, your sources on head lice are sadly behind the times (1). Last September, the Bug Buster Kit became available on NHS prescription in the UK. For overseas readers, I must explain that children have the right to free treatment for head lice in the UK. The kit may now be supplied to meet this right, the only alternative to failing insecticides. It contains the best combs and full instruction for the treatment of head lice using the Bug Busting wet combing method. The establishment of an informed partnership between doctors and patients to defeat lice has advanced significantly as a result. Making the kit prescribable, firstly saves doctors and nurses time on explaining to parents how to reliably identify live lice. Detection by the highly sensitive Bug Busting method (2) proves that an infestation is active. Parents may then choose to buy treatments for each infested member of their family, but they are no longer dependent on this, because the kit is re-usable for treatment. Prescribers are freed of the obligation to provide a treatment per child per infestation and make considerable savings on their drugs budget. Finally the Nit Buster comb comfortably sweeps off those worrisome, unsightly eggshells after Bug Busting. In 2001, Plastow and colleagues reported on this improved model of the Bug Buster Kit (3). They found children enjoy wet combing with the new yellow Bug Buster. In over 50% of cases, their carers succeeded in clearing lice after combing twice a week for 2 weeks, and the problem of re-infestation from sources outside the family was recognised and resolved by day 24, in the rest of the cases (100% success rate). In 1996, David Hall saw the importance of becoming expert on head lice to encourage the development of a sustainable solution (4). He became the President of the Royal College of Paediatrics and Child Health and received a knighthood in the January 2003 honours list. 1.Smith R. Editor’s Choice, Head lice: boring for doctors, important to patients. BMJ 2003; 326:7401 2. De Maeseneer J, Blokland I, Willems S, Vander Stichele R, Meersschaut F. Wet combing versus traditional scalp inspection to detect head lice in schoolchildren: observational study. BMJ 2000; 321:1187-8 3. Plastow L, Luthra M, Powell R, Wright J, Russell D, Marshall MN. Head lice infestation: bug busting vs. traditional treatment. J Clinical Nursing 2001; 10: 775-83 4. Ibarra J, Hall DMB. Head Lice in Schoolchildren. Archives of Disease in Childhood 1996;75:471-3 Competing interests: Co-ordinator for the charity, Community Hygiene Concern, which runs the not-for-profit Bug Busting programme - www.chc.org/bugbusting |
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Carol Teasdale, N/A .
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In my opinion doctors should not prescribe lotions or recommend them. It helps to perpetuates the notion that head lice are socially unacceptable, GP appointments are taken up and lotions are expensive. They are simply a bane and a hazard of growing up, but can make a worried mother very ill. I am sure that it will be found one day that they have a use to a child's maturing immune system. So, buy a cheap, thick, white, hair conditioner designed for dry hair. Wash and coat your child's hair well in the conditioner, making sure that it is massaged right down to the roots. Leave it on for about ten minutes. Comb through the hair with a nit comb, sometimes known as a dust comb, which is available from any chemist. Wipe the comb sideways on a light coloured towel after each pull through the hair and rinse it under running water frequently. The comb should always be taken from the scalp right down to the bottom of the hair. The lice can't hang onto the hair and will slide off onto the comb; they are visible on the towel. They will still be alive so keep the towel well away from other people’s hair. Repeat next day and so on until no lice are found, after that on a weekly basis. Remember the eggs have yet to hatch and must be combed out before they lay! Tea Tree oil is reported to discourage hair lice in the first place. As far as I know this has no scientific basis, but it may work. It would probably help with any sores a child has developed from scratching as it is a natural antiseptic. If you have a boy keep his hair short, if you have a girl tie her hair up for school. Contrary to what is written in the article, lice will walk along a loose hair strand onto the waiting head of another child (ask a child who watches them on another child’s head). Tying the hair tight would make it more difficult to move toward the scalp, not easier. Teach them to move their head away from contact with others, particularly their teachers. If a school has very bad cases of head lice parents can be encouraged to tie up long hair in tight styles, and use head coverings during break times and when children have close contact with others i.e. cloth triangular scarves for girls and caps for boys in primary schools. It’s summer so they should be wearing head protection anyway. Be honest and tell other parents straight away if your child has lice; don’t lay blame on to anyone else. Placing blame on a third party encourages a stigma. Always inform The school, youth club, Brownies, Scouts etc... Some schools hire out combs that can electrocute the lice for a small charge. So informing them gives other parents a chance to treat their child, which is ultimately in your own best interest. No one is exempt from any of the little visitors children get, it's foolish to think otherwise, treat the whole family, including parents and grandparents. It takes time, but there is nothing wrong with spending time on your child's health, it's a part of parenting. Make a nit comb an essential accessory of any teen wash bag. Groups of teenagers today can be very close in their greetings, but extremely embarrassed when it comes to buying some health products. They will quietly go away and use a comb if they have it. There is no need to use any chemicals of any kind; it’s an expensive waste of time. Children will simply catch them again and again from other untreated individuals. Children treat lice as an everyday part of life, its adults who teach them it’s socially unacceptable to discuss them. The article in this weeks BMJ by Beth Nash (1) seems disrespectful of children’s rights to grow up free of as many harmful chemicals and pesticides as possible. It totally ignores the fact that chemical treatments can only be successful long term in an environment where every child is treated at the same time, this would never happen in a school. Therefore parents could not keep on and on chemically treating them during subsequent attacks. Incidentally, head lice which are detached from their host live a long time afterwards. I can’t see how the article writers don’t know this? (1) Even treated lice often revive if let in a dish overnight to recover. Put them under a microscope for a few days and see for yourselves just how long, and what, they can survive! 1. Extracts from "BestTreatments" , Treating head lice, Beth Nash, physicians editor, BestTreatments BMJ 2003;326:1256-1257 (7 June) http://bmj.com/cgi/content/full/326/7401/1256?ijkey=fe2927083148a92cfca903d88568578d9e1c454b&keytype2=tf_ipsecsha Competing interests: None declared |
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Sylva Dolenska, Consultant Anaesthetist William Harvey Hospital, Kent TN240LZ
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Dear Deborah, I quite agree that there are many things wrong with the BMJ articles and the accompanying editorial. What is also worrying is that the Daily Telegraph published on the same day extracts from the article, reiterating the same misconceptions presented as "evidence" or "research". I have written several responses; as one who has been affected I feel that I acquired considerable experience. One of the problems is, as Wendy McLellan says in her reply, that nothing beats curing the primary source. Abandoning the "no nits" policy (not that many schools in the UK have them, anyway) makes sense on the grounds presented but does nothing for curing the primary source. Some parents (often those of the primary source) do not know best, i.e. do not know about the infestation or how to treat it, and it is the school nurse who is in the best position to do something about it. Schools elsewhere in the world would be shut for a few days if there is a headlice epidemic, and that tends to sharpen the mind of parents to the problem. At the very least, during an epidemic the school nurse should check heads and actively seek out parents of affected children to help them get rid of the infestation. This could be done in the form of the school letter, given to all children when infestation is reported. The policy should be re-named "no lice policy" and re-inforced, not abandoned. I find it worrying that the Telegraph, read by millions of readers, can reprint things which plainly go against common sense (see also replies to the actual clinical review section). As a president of the National pediculosis association, are you going to be more proactive in dispelling the myths perpetuated by the clinical review, and are you going to advise Local Educational Authorities in the same vein? May I also point out (it has also been pointed out by several readers in the replies section) that lindane is not available in the UK as it was voluntarily withdrawn, and the data on toxicity of the other agents is actually fairly favourable. Proprietary preparations may still have their place in some cases, as bug busting requires a high degree of determination and perseverance. Competing interests: None declared |
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Anita M. Bailey, Independent researcher C/O Microbiology & Parasitology Dpt, University of Queensland, St Lucia 4072, Australia, H. Phillip Petersen
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Editor, recent lice articles, including ‘BestTreatments’ (1), need updating. Without serious medical investigation, head lice advice has sometimes relied on speculation from a few entomologists. For eg, advice to avoid hair-cutting originated from a well-meaning but baseless suggestion in the 1970’s. Resistance to pediculicides is well-documented. Over-reliance on insecticidal treatment is putting children’s health at risk. Non-drug measures should be recommended. Unchecked transmission in schools is causing higher prevalence. Routine screening is advised. Without it, treatment decisions should take into account repeated exposure. (2, 3). Head lice are not harmless. They can cause dermal injury and sensitization. Some people resort to household poisons to relieve persistent cases. A disproportionate amount of family time and money is wasted. Millions (pounds) are spent in each of the UK, USA and Australia on louse treatment annually (3). Detection and removal of lice in some hairstyles is more difficult than previously thought. Our group has confirmed life-stage sizes as small as 0.6mm. Louse camouflage and various hair factors can cause false negatives and under-estimations. Without such knowledge, clinical product assessments are questionable (4). Those who use a tiered diagnostic approach to screening have found that manual treatment is more successful than chemical. Fine-toothed combing is so helpful that it is one of the tools by which therapies are better assessed. Perhaps only head-shaving and microscopic examination are the gold standard (2, 3, 4). Dry-hair parting with a lamp-magnifier can help practitioners to identify continuous egg deposition at the scalp-hair margin outwards of chronic cases. Old ‘nit’ removal facilitates examination. Patients who remove eggs may also find hidden lice. Further fine-combing may helpfully confirm the live lice (2, 3, 4). Removed head lice are alive but probably less of a concern than direct transmission or unrecognised relapses. Longer or thicker hair impedes detection and removal of resistant infestations. Hair-shortening improves comfort and access to residual lice. Pediculosis is not self-limiting and undetected failures (some relapsing monthly for years) are common in longer hair of girls (3). Lice can transfer instantly across hair tresses with a vigorous rub. Severely neglected head lice may also bite further down the body. New biological findings place head and body lice in the same species. Body lice carry typhus, relapsing fever and trench fever, which are reemerging overseas. We suggest that pediculicides should be reserved to assist with control of such outbreaks. Lack of thorough screening and treatment will allow more resistant lice to proliferate (5). (1) 1. Nash B. Treating head lice BMJ 2003; 326: 1256-8. (2) Bailey AM, Prociv P. Persistent head lice following multiple treatments: Evidence for insecticide resistance in Pediculus humanus capitis. Australas J Dermatol 2000; 41: 250-54. (3) Bailey AM, Prociv P. Pediculus humanus capitis infestations in the community: A pilot study into transmission, treatment and factors affecting control. Australian Infection Control 2001; 6: 95-101. (4) Bailey AM, Prociv P. Head lice appearance and behaviour: implications for epidemiology and control. Australian Infection Control 2002; 7: 62-71. (5) Bailey AM, Prociv P, Petersen HP. 2003. Head lice and body lice: shared traits invalidate assumptions about evolutionary and medical distinctions. Australian Journal of Medical Science 2003; 24: 48-62. Competing interests: None declared |
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Jo Ann Rosenfeld, Asst Professor Johns Hopkins 21113, 1132 Annapolis Rd, Odenton MD USA 21113
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While we are educating school nurses and teachers not to become hysterical about head lice and try not to over treat it, submit children to humiliating "lice checks," and send children home until all the nits are gone, can we educate them about "pink eye" as well? Why are children sent home, not to return until treated. First, it is very contagious, but it has already been spread by the time the child has it. Second, it is viral. There is no treatment that does anything except mollify the school system. Let's send the kids back to school with pink eye, and save everyone trouble. Competing interests: None declared |
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Theo Fenton, Consultant Paediatrician Mayday Hospital, Croydon CR7 7YE
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Dear Sir, The UK Public Health Laboratory Service produced some excellent evidence-based guidelines a few years ago. Unfortunately, few teachers/school nurses seem to be aware of them. I keep a copy in my car, and my affected son clutches the relevant page when I drop him at nursery. The guidelines are at: http://www.phls.org.uk/%5Ctopics_az/schools/schools.pdf Conjunctivitis is discussed on page 5, and head lice on page 20. Competing interests: None declared |
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Karen M Dacy, parent Monash university 3101
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As a parent, I have spent an inordinate amount of money on Permethrin, Lindane and Malathion based products and have on more than one occasion, after following instructions conscientiously, combed live, healthy adult lice out of my childrens' hair immediately following the recommended treatment time. Out of curiosity and desperation I put some live lice under a microscope and saturated them in each of the products, then undiluted lemon juice, tea-trea oil and methylated spirits (different lice, separate trials). After 10 minutes not one was dead. Conditioner killed the lice within a couple of minutes, as did olive oil. My point is this: what works in one case is difficult to prove for populations, given the variables in how the method is applied. It appears to my family that death by suffocation (as I believe is the cause with oil -based products) is the most effective as long as every louse is found and killed before reproductive age, and if reinfection can be prevented. In many cases I personally suspect that reinfection takes place almost immediately after treatment, thus it appears the method was ineffective. My treatments regularly appear to be "ineffective" during term time, but during the school holidays all evidence of lice disappears within 10 days of treatment. Furthermore, it is difficult to see how head lice will develop a resistence to suffocation, hence oil based treatments pose a lesser threat to the community in the future. Incidentally, I believe that tea tree oil is technically not an oil at all but an ester or esters.(?) To judge effectiveness, it is surely necessary to chose an isolated population and ensure that they remain isolated throughout the period of clinical trials and that the treatment is applied consistently, by the same people. Finally, it would be heartening to see medical researchers draw more extensively on evidence provided by parents, who currently are amassing an enormous amount of field experience in the area and seem to be converging towards a single conclusion; that the pesticide brands are not working, while conditioner and combing is. Karen DAcy Competing interests: None declared |
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