‘No nits’ policy wrong-headed, say doctors

Cathy Tarala is armed with a headlight, a magnifying visor over her eyes and a comb called “The Terminator.” Her enemy — tiny but resilient — is pediculus capitis. Most parents know it as head lice.

Cathy Tarala

Cathy Tarala

TORONTO — Cathy Tarala is armed with a headlight, a magnifying visor over her eyes and a comb called “The Terminator.” Her enemy — tiny but resilient — is pediculus capitis. Most parents know it as head lice.

On this winter morning in the pristine kitchen of a Toronto client, Tarala is methodically separating sections of long, fair hair on her eight-year-old charge, using an instrument that looks like a pickup stick.

She plucks a speck from the scalp, places it on a white paper towel and examines it under a hand-held magnifier, so she can see the distinctive six legs of the brownish newly hatched louse.

“That’s all you need to confirm they’re here,” she says.

Tarala is a contractor for the Lice Squad, a $60-an-hour service that treats lice (pediculosis) in homes, performs head checks in schools and trains volunteers on school committees on how to spot them.

At many schools and daycares, regular lice screening is as much a part of the routine as safe arrival calls. Getting rid of lice can be tricky, time-consuming and expensive, requiring hours of combing and checking for live lice along with the tiny, brownish eggs that they leave glued to hair shafts close to the scalp.

By the time today is over, this family will have spent more than $200 for the 90-minute treatment, Lice Squad supplies to repeat the process and the special shampoo and comb bought earlier at a pharmacy.

The mother, a lawyer, has missed three days of work since being summoned to pick up her child after a routine check at the school’s daycare. The child, calm and patient this morning, cried when she was sent to the office to wait.

“What about parents who can’t just take the time off work?” wonders her mother, who didn’t want the family identified. “And what if they can’t afford all this?”

Major school boards in the Toronto area have “no-nits” policies. That means even if a lice shampoo or wet comb treatment has removed live ones, children aren’t allowed back into school if any eggs are left. Monitoring and dealing with it is left up to individual schools.

What many parents may not know is that the practice flies in the face of many medical opinions.

Organizations like the Canadian Paediatric Society, the U.S. Centers for Disease Control and Prevention and the American Academy of Pediatrics discourage school screening and say “no nit” policies are not based on sound medical rationale.

Entomologist Richard Pollack calls screening “a tremendous waste of time” and says no-nit policies exclude and ostracize children for something that is a nuisance but not a health issue.

“They (head lice) are not known to transmit anything — except hysteria, perhaps,” says Pollack, who works for Harvard University’s laboratory of public health entomology and has studied head lice for 20 years.

His reasons, outlined on his website (www.hsph.Harvard.edu/head lice), include a high incidence of misdiagnosis by improperly trained school staff and parents. Pollack cites his 2000 study in the Pediatric Infectious Disease Journal, which invited health care personnel and lay personnel to submit specimens they used to diagnose cases of pediculosis.

Lice or their eggs were not present in more than one-third of cases. Of the rest, he says, half included a louse or viable egg but half had the remnants of hatched eggs or dead embryos, which do not qualify as active cases requiring treatment — they are not transmissible.

“You could flip a coin as your diagnostic criteria and be right more often than the way it’s done in schools,” Pollack says. “Can you think of any other medical test that would be allowed with a failure rate that great?”

Pollack notes that not all eggs will hatch and empty cases will remain on hair shafts indefinitely unless they are fastidiously combed out using a fine-toothed lice comb. He argues that live lice — not nits — should be the only criteria for treating lice and, even then, “excluding presumably infested children from school is unwarranted.”

“If you have head lice, take care of it,” he says. “But I certainly would not punish the child or his or her parents.”

In Toronto, one parent council member says privately that screening and removal of infested kids is “all driven by the parents, not the school.”

While a case of lice isn’t serious, no one wants to go through the ordeal, says the mother of three, who recently saw it sweep through her family. Dealing with it “takes over the house,” she says.

It’s next to impossible to know how common head lice are. To families who have had repeated cases or been unsuccessful at treating infestations, it may feel like a growing problem.

As Pollack notes, there are no reliable statistics anywhere in the world. Public health departments, including those in the Toronto area, don’t keep statistics because it isn’t considered a health problem and, therefore, no reporting or tracking is required.

Karin Kutasewich, owner of the central Toronto franchise of the Lice Squad, said her business has been particularly busy, and included 25 checks at public and private schools in January. At one elementary school, 79 cases were diagnosed among 530 students, while at a school of 550, there were 28.

Last year, her franchise did 1,085 home visits, up from 852 in 2008, and 103 school checks.

But Marie Amato, a registered nurse with the Toronto District School Board’s pediculosis program, says school cases have declined over the past few years. “It’s not a big issue. It is under control.”

She spends her days doing school checks and says, typically, a team will find four active cases in a school of 400.

Pollack doesn’t believe head lice are any more prevalent now than in previous generations. “I think the difference is we’re a lot more open about it.”


• Lice are equal-opportunity infestors, with no preference for gender, hair types or socioeconomic or ethnic background. Head lice are not a sign of poor hygiene and can thrive in clean hair.

• Buzz cuts don’t help. Lice may be easier to spot but lice-comb treatment is harder because hair is too short to grip.

• Lice can’t jump or fly and are only transferred by head-to-head contact or, on occasion, through hairbrushes, hats or other items in contact with hair.

• Eggs take eight to 10 days to hatch. A female lays about five a day; not all will hatch.

• Lice cannot survive more than a day or two without a human host and do not live on couches, dogs or in classrooms.

• Treatments include over-the-counter insecticide shampoos recommended as two treatments about a week apart and/or mechanical removal using lice combs daily for about two weeks. Some people report success suffocating lice by applying olive oil for four hours a day.

• There is evidence that a growing population of lice is insecticide resistant.

• Washing bedding, hair accessories, nightclothes and drying at high heat is recommended.

Sources: www.licesquad.com and