Bed Bugs, Pinworms, and Others, Oh My!

Editor’s note: This text-based course is an edited transcript of the webinar, Bed Bugs, Pinworms, and Others, Oh My!, presented by Charlotte Hendricks, PhD.

Learning Outcomes

After this course, participants will be able to:

• Identify signs of common pest infestation.
• Describe appropriate and effective treatment for each pest.
• List steps to prevent the transmission of pests.

Introduction

Today, we're delving into bed bugs, pinworms, and other critters we'd rather not have in our early childhood centers. I'll present each pest by describing its habitat, identifying signs, discussing symptoms and health concerns, treatment options, prevention techniques, and environmental cleaning. While some information may overlap among the four pests we'll discuss, I'll highlight differences in treatment approaches. The pests covered are head lice, bed bugs, pinworms, and scabies. It's essential to note that their presence doesn't imply poor hygiene.

Head Lice

Let's delve into the world of those pesky little critters known as head lice. Pediculosis refers to the infestation with lice, tiny parasites that survive by feeding on human blood, primarily from the scalp. These head lice are exclusive to humans and do not inhabit animals like dogs or cats. While head lice predominantly reside on the human head, they can briefly survive off the scalp, clinging to clothing, bedding, hats, earphones, and other surfaces. It's important to note that we're specifically addressing head lice here, distinct from body and pubic lice.

Identification

Measuring about the size of a sesame seed, they're challenging to spot as they avoid light and move swiftly. Typically, a child may harbor no more than 10 to 20 live lice on their scalp at a given time, further complicating detection.

Figure 1. Illustration of head lice egg on a hair shaft. Source: CDC.gov

Head lice are often identified through the presence of their eggs, commonly referred to as nits. These nits are laid in small egg sacs along the hair shaft, firmly attached close to the scalp, as seen in Figure 1. Live infestations are indicated by nits within a quarter of an inch from the scalp. As nits hatch, the empty casings remain on the hair strand, becoming more visible as hair grows, usually about half an inch per month. It's easy to confuse other substances with nits, such as dandruff, hair product residue, or scalp debris, underscoring the need to differentiate between nits and other materials.

Symptoms

Contrary to popular belief, head lice don't always trigger itching. While some individuals may experience a tickling sensation or a feeling of movement in the hair, others might exhibit irritability or difficulty sleeping due to an unknown cause. Scratching induced by such sensations can lead to sores on the scalp, not from lice bites themselves but from scratching, potentially paving the way for bacterial infections.

Despite their nuisance, head lice aren't inherently dangerous and don't transmit diseases like ticks or mosquitoes. The itching results from an allergic reaction to the lice's bites, similar to reactions caused by other bug bites. However, persistent scratching can lead to skin irritation, eczema, impetigo, and bacterial infections.

Treatment

Now, let's turn our attention to lice treatment. While head lice aren't harmful, eliminating them is essential to prevent their spread. Over-the-counter lice products are readily available at retailers like Walmart, Walgreens, Kroger, and pharmacies. 

The most effective over-the-counter products contain one of two pesticides: pyrethrum or permethrin. Pyrethrum is derived from Chrysanthemum flowers, while permethrin is a synthetic compound. Both are considered safe and are specifically formulated for lice treatment. Another product you might come across is dimethicone, but it doesn't kill lice. Pyrethrum and permethrin function as neurological toxins, effectively eliminating lice, whereas dimethicone purportedly suffocates them. However, research suggests dimethicone is only about 70% effective, making it less reliable.

When selecting a lice treatment product, prioritize those containing pyrethrum or permethrin. Look for labels indicating effectiveness against both lice and eggs, or nits. Remember, efficacy may vary among products, so following the instructions is crucial. Typically, the treatment involves washing the hair with a basic shampoo, not a conditioner-containing one, to ensure the active ingredients can penetrate the hair shaft and eliminate the lice. After application, adhere strictly to the recommended exposure time, usually around 10 minutes, before rinsing thoroughly. Avoid leaving the product on longer than instructed, as it could potentially harm the child's skin.

After treatment, it's crucial not to wash the child's hair for two to three days. This allows the treatment to thoroughly soak into the nits and eggs, ensuring their eradication. While some products claim to kill lice in a single application, this may not always be true. Generally, a second treatment is necessary to eliminate newly hatched nits. Although modern products are more effective than those of the past, lice have also developed resistance, making follow-up treatments essential.

Resisting the urge to use garden pesticides or outdated treatments like lindane is imperative. These can lead to severe reactions and are not formulated for head lice treatment. Regarding exclusion policies in childcare programs, head lice exclusively inhabit the scalp and are transmitted through direct head-to-head contact or by sharing personal items like hats or earphones. If head lice are detected in a childcare setting, sending affected children home is unnecessary. However, informing their families is crucial, as they must initiate treatment promptly. While some institutions used to enforce a "no nit" policy, it's now understood that dead nits pose no risk. Instead, communication with families about the presence of head lice is essential to ensure thorough treatment and prevention within the community.

As for transmission, head lice cannot fly or hop; they can only crawl. Thus, minimizing contact between personal items in childcare settings, such as hats and coats, is vital to prevent lice spread. Hang coats so they don't touch, and tuck hats and gloves into the coat sleeves. Sleeping mats should be individually labeled, stored separately, and regularly laundered to mitigate the risk of transmission further.

Environmental

To effectively manage pests in your environment, it's crucial to adopt Integrated Pest Management (IPM). This approach involves altering the environment to deter pests alongside targeted elimination methods. Whether dealing with mosquitoes, snakes, mice, or head lice, IPM offers a safer and more environmentally friendly solution. You can find more information on IPM at epa.gov.

Adult head lice can survive off the human body for two to four days at room temperature. However, they primarily inhabit the scalp and do not thrive on surfaces. Therefore, using pesticides on environmental surfaces is unnecessary and potentially harmful. Popular home remedies, such as mayonnaise or essential oils, are often ineffective against head lice and can cause adverse reactions. It's essential to rely on proven treatment methods and avoid unnecessarily using pesticides on shared items or environments.

When managing head lice, thorough cleaning of clothing, linens, and personal items used in the preceding four days is recommended. Machine washing and drying these items effectively eliminates any potential infestation. Head lice can survive for about two to four days without a human host, with a maximum lifespan of approximately two weeks. The duration of their survival depends on factors like room temperature. To prevent the spread of head lice, it's advisable to take certain measures. For items that cannot be machine washed, such as plush toys, you can eliminate any potential infestation by sealing them in plastic bags for two weeks. This duration ensures that any surviving lice will perish without a host. Also, brushes and combs can be soaked in hot water at least 130 degrees Fahrenheit to eliminate lice or nits.

Regular cleaning practices are essential for preventing and managing head lice infestations. Vacuuming floors, carpets, and furniture helps remove dust, debris, and stray lice or eggs. Damp mopping floors further aids in maintaining a clean and pest-free environment. By incorporating these practices into your routine, you can effectively minimize the risk of head lice infestations and ensure a healthy living environment.

Understanding head lice's transmission and life cycle is crucial for effective management. While head lice infestations can occur in anyone regardless of hygiene, certain hair types are less susceptible due to the shape of the hair shafts. It's important to dispel misconceptions about head lice and focus on practical prevention and treatment methods.

Understanding the transmission and life cycle of head lice provides valuable insight into how similar pests operate and how to manage them effectively. The principles of preventing and treating infestations—such as minimizing direct contact, maintaining personal hygiene, and regularly cleaning the environment—apply to various pests beyond just head lice. As we explore other critters, you'll notice overlapping strategies for dealing with them, emphasizing the importance of an integrated approach to pest management. This holistic perspective helps tackle head lice and equips you with the knowledge to handle other pest-related challenges more effectively.

Bed Bugs

Bed bugs are particularly unsettling because they pose a greater challenge to eradicate than head lice. While head lice are confined to the scalp and can be eliminated with targeted treatment, bed bugs infest the environment, making eradication more complex.

Identification

These flat, oval-shaped pests, approximately the size of an apple seed, are reddish-brown and wingless, as seen in Figures 2 and 3. While they can feed on the blood of animals and humans, they prefer human hosts due to our lack of dense body hair, providing easier access to their blood meals. Young bed bugs, known as nymphs, are smaller and often translucent with a whitish-yellow hue, making them nearly invisible. Their eggs, about the size of a pinhead and pearl white in color, are also difficult to detect.

Figure 2. A bed bug on a human's skin. Source: CDC.gov via Wikimedia Commons

Figure 3. A bed bug next to a ruler for size comparison. Source: Giles San Martin via Wikimedia Commons

Bed bugs reproduce rapidly, with the ability to lay eggs daily. Without intervention, a small initial infestation can quickly escalate, with 40 bed bugs potentially spawning a population of nearly 6,000 within six months. Remarkably, bed bugs can survive up to a year without feeding, adding to the difficulty of eradication efforts.

Figure 4. Bed bugs near a wall outlet. Source: EPA.gov

Figure 5. Bed bugs on the canvas strap of an old box spring covering. Source: EPA.gov

These pests gravitate towards areas where people sleep, such as mattresses, box springs, and behind headboards. They can also hide in luggage, boxes, and objects near the bed, including outlets, wallpaper, and carpeting near baseboards, as seen in Figures 4 and 5. Telltale signs of a bed bug infestation include blood spots on sheets or mattresses, tiny black dots (fecal matter), discarded exoskeletons from molting, and a musty odor around the bed. When staying in hotels or unfamiliar accommodations, inspecting mattress corners and seams for signs of bed bugs is advisable to avoid infestation.

Symptoms

Some individuals may exhibit visible bites from bed bugs, while others may not show any signs. Bed bug bites typically appear as itchy and inflamed spots, often darker in the middle, and may form a line or cluster. Although the bites are not harmful and usually clear without treatment, individuals allergic to them may experience more severe reactions. Similar to reactions to mosquito bites or bee stings, allergic individuals may develop severe itching, blisters, or hives. As with head lice, bed bugs are not known to spread disease, but excessive scratching can lead to skin irritation and bacterial infections like impetigo.

Bed bugs are nocturnal feeders, preferring to feed at night when hosts are asleep. They are attracted to human hosts by following carbon dioxide emissions, sensing body heat, and detecting body odor. In an early childhood environment, bed bugs may seek out sleeping children during nap time. While bed bugs are not considered medically dangerous, their presence can cause discomfort and allergic reactions in some individuals.

Treatment

Identifying signs of bed bugs, such as colored stains on mattresses or furniture, is crucial for early detection. If bed bugs are found in a mattress or furniture, disposal may be the most effective solution, as bed bugs are notoriously challenging to eradicate. When purchasing used items like mattresses or furniture, it's essential to exercise caution and avoid items of unknown origin or potential infestation.

Using synthetic mattress and box spring covers can effectively prevent bed bugs from infesting mattresses or trapping them if they are already present. These covers act as a barrier, blocking bed bugs from reaching the mattress and preventing their escape if they are already inside. Additionally, heat treatment is an effective way to eliminate bed bugs and their eggs. Laundering items such as rugs, sheets, bedspreads, and pillows in hot water and drying them in a hot dryer can kill bed bugs and remove their eggs.

On hot days, the interior of a closed vehicle can reach temperatures above 121 degrees Fahrenheit, which is lethal to bed bugs. Placing luggage or items potentially infested with bed bugs in a closed vehicle on a hot day can effectively kill the pests.

Bed bug infestations can lead to complaints in early childhood programs, but addressing them promptly and professionally is essential. While bed bugs are not necessarily a sign of poor sanitation, cluttered environments can make it more challenging to control infestations. Educating families about bed bugs, encouraging them to check their homes, and maintaining cleanliness can help prevent and manage infestations. Bed bugs can be transmitted between home and early childhood settings, particularly if children live in environments like hotels or homeless shelters where they may be more exposed to bed bugs.

Environmental

Taking environmental precautions can help prevent bed bug infestations or limit their spread. Keeping personal belongings and items off the floor, such as hanging backpacks and coats, can reduce the risk of bed bugs crawling into them. When staying in hotels or similar accommodations, keeping suitcases and belongings away from the bed and floor can also help prevent bed bug encounters.

If bed bugs are detected in an early childhood program, it's important to take prompt action to address the infestation. All bedding and cots should be washed thoroughly, and efforts should be made to ensure that families are also treating their homes if necessary. Contacting a pest management professional who is trained and experienced in dealing with bed bugs is crucial for effective control.

When using pesticides in the childcare environment, caution must be exercised, especially in areas where children play and sleep. It's essential to follow proper procedures and guidelines when applying chemicals to avoid any potential harm to children. Quarantining the room where bed bugs are found until it can be inspected and treated is also important to prevent the spread of infestation to other areas.

While home treatments such as sprays purchased from stores can be effective for individual households, it's advisable to seek professional assistance for bed bug infestations in childcare settings. Professionals can provide targeted treatments and ensure that proper safety measures are followed to protect children and staff from exposure to pesticides.

Pinworms

Pinworms are a common issue, especially among children. Pinworms are a type of roundworm that primarily affects humans. Unlike other worms that can affect pets, pinworms are specific to humans and do not infect animals. These parasites are typically small and white, resembling tiny threads, and they are often visible to the naked eye as they wiggle, especially around the anus or in stool. While pinworm infestations are not usually considered harmful, they can cause discomfort and itching, particularly at night when the female worms lay their eggs around the anal area.

Pinworms typically reside in the lower part of the large intestine, near the anus. At night or during periods of rest, such as nap time, the female pinworms may exit the anus to lay their eggs in the folds of the surrounding skin. After laying their eggs, the adult worms usually die. However, this egg-laying process can cause significant itching and discomfort for the affected individual, especially at night when the itching may be more pronounced.

If a child is observed scratching the anal area, particularly during nap time or at night, it may indicate the presence of pinworms. The itching is often a result of the irritation caused by the movement of the worms and the deposition of their eggs.

After the eggs are laid, they typically hatch within two to four weeks, continuing the pinworm life cycle. This cycle of egg laying, hatching, and reinfection can perpetuate the infestation if not properly treated and managed.

Identification

Figure 6. Pinworms in a stool sample. Source: Vaio1488, CC BY 3.0, via Wikimedia Commons

Upon defecation, especially with softer stools like the one depicted in Figure 6, it's conceivable to spot a worm amidst it. I've seen cases where these little white worms are crawling all over it because they're inside the anus and come out with the bowel movement. This visual inspection may reveal their presence. Additionally, an examination with a flashlight can unveil these creatures around the child's anal area as they emerge to lay eggs. Alternatively, wrap cellophane or adhesive tape wound sticky-side out around a Popsicle or craft stick and gently touch it to the skin around the anus, then seal it in a plastic bag. Do this for three consecutive days. Sealing the tape in a plastic bag allows for clinical analysis under a microscope if you take it to the doctor.

Symptoms

Most people experience no symptoms, though some may notice occasional itching, particularly at night. Restless sleep, bedwetting, or vaginal irritation in young girls could also be indicators. Like head lice and bed bugs, pinworms are generally harmless, yet persistent scratching from the itching may result in irritation or infection.

Treatment

An over-the-counter product called pyrantel pamoate is available without a prescription. While some medications are accessible only with a prescription, you can ask a pharmacist about options containing this ingredient. It's crucial, however, to consult your child's healthcare provider before administering any medication to an infant or toddler, as their bodies may respond differently to medications and dosages.

Like certain lice treatments boasting single-dose effectiveness, many pinworm treatments make the same claim. However, this isn't always accurate. I recommend following the instructions by administering the initial dose and giving another dose two weeks later. Here's an example. During my tenure at a program, the health coordinator approached me with a dilemma involving a mother whose child continually battled pinworms despite her efforts. After speaking with the visibly distressed mother, it became clear she had diligently followed all the prescribed cleaning measures. However, when I inquired about the medication, she was unaware of the need for a second dose.

At that time, obtaining the medication required a prescription, and she had obtained it from the Health Department without being informed about the necessity of a second dose. While the initial dose eradicated the live worms, it failed to eliminate the eggs. Consequently, when the eggs hatched two weeks later, the cycle repeated, leading to reinfection. Administering a second dose poses minimal risk to the child and is far preferable to enduring another round of treatment months later.

Exclusion protocols differ for pinworms compared to head lice. A child diagnosed with pinworms should be excluded from the childcare setting until after receiving the first dose of medication. Once a child is known to have pinworms, the family should promptly pick up the child, administer the medication, and keep them home until the initial treatment is completed. Furthermore, all members of the child's household should undergo treatment simultaneously since pinworms are highly contagious. Afterward, it's essential to ensure that everyone in the household receives the second dose of medication as directed.

Environmental

Maintaining strict hygiene practices is crucial in preventing the spread of pinworms. This includes washing all bedding and towels in hot water, trimming fingernails short, changing underclothes and pajamas daily, and replacing bed linens after treatment and at least weekly after that. Pinworms are transmitted via the fecal-oral route, primarily through contact with contaminated hands. Short fingernails mitigate the risk of egg transmission, as eggs can become lodged under longer nails and spread through touch. Caregivers and teachers are particularly susceptible to exposure due to frequent contact with toys, diapering, and toileting activities.

Pinworm eggs can survive outside the body for up to two weeks, making thorough cleaning essential. Vacuuming with a bagged vacuum cleaner, wet mopping floors, and regularly laundering all linens and toys are effective measures to remove eggs from the environment. Make sure you throw away the vacuum bag with the eggs after vacuuming, even if it's not full. Additionally, frequent handwashing, especially after diapering, before eating, and after handling toys, is crucial for preventing transmission. It's advisable to shower rather than bathe during an infection, as bathwater can become contaminated with eggs, potentially leading to cross-contamination among bathers. Avoiding co-bathing during an infection reduces the risk of spreading pinworms among household members.

Scabies

The final pest we'll discuss is scabies, which differs from the previous examples. Scabies refers to an infestation of the skin caused by microscopic mites. These mites burrow into the upper layer of the skin, where they live and lay eggs. Typically, the infestation involves just a few mites, around 10 to 15 per person. Therefore, the primary goal is to eliminate these mites from the skin.

Identification

You might notice small, crooked, gray-white, or skin-colored lines on the skin, indicating the burrows created by the scabies mites. If you were to see these markings on a child's skin, you might initially mistake them for poison ivy or an allergic reaction. Recognizing scabies requires either familiarity with its appearance or the expertise of a health professional.

Symptoms

Intense itching is a hallmark symptom of scabies, often accompanied by a rash resembling pimples, blisters, or scales. However, these symptoms alone may not immediately suggest scabies, as they could be mistaken for other skin conditions or reactions to chemicals like soap. Scabies can affect various parts of the body, from widespread areas to specific locations such as the wrists, fingers, nipples, genitals, belt line, or buttocks. Figure 7 shows scabies on the hand and wrist after one week of treatment.

Figure 7. Scabies on the hand and wrist after one week of treatment. Source: Public domain, via Wikimedia Commons

In infants and very young children, scabies commonly affects the head, neck, face, palms, and soles of the feet. Like the other pests discussed, scratching can lead to skin sores, which may become infected by bacteria, potentially resulting in conditions like impetigo. While scabies lesions may initially appear as small spots, scratching can exacerbate the condition, leading to a more extensive spread.

It's important to note the rare occurrence of crusted scabies in children. This form of scabies involves a significant infestation of mites, far beyond the typical 10 to 20 mites seen in regular cases. While uncommon in children, awareness of this form is crucial, particularly in environments where access to preventive and medical care may be limited, such as homeless or impoverished households. In such cases, an older family member with crusted scabies could transmit the condition to children, emphasizing the importance of understanding the family and home environment to address recurring cases effectively.

Treatment

The treatment for scabies differs from other conditions discussed. Specific products known as scabicides are used to eliminate the mites, with some also capable of killing the mite eggs. However, it's crucial to note that effective scabicides require a prescription and are unavailable over the counter. Despite living in rural areas where unconventional remedies may be suggested, it's essential to avoid using veterinary or agricultural products and instead opt for treatments specifically formulated for human scabies.

Administering scabicide treatment involves applying a cream or lotion to the entire body, from the neck down to the toes. Fingernails must be trimmed, and medication should be applied to the fingertips. Typically, the cream is left on for eight to 12 hours, often applied before bedtime and washed off in the morning. Additional treatments may be necessary if new rashes or burrows appear, and it can take two to four weeks for itching and rash to completely subside after treatment.

While healthcare providers may prescribe oral medications or recommend antihistamines or steroid creams to alleviate itching, seeking professional medical advice is paramount for effective scabies treatment. Exclusion from childcare settings until completion of the first round of treatment is advised, and it's crucial to ensure that all household members receive treatment simultaneously, even if asymptomatic. Given scabies' highly contagious nature, thorough washing of clothing and bedding is essential, as it can easily spread through direct skin-to-skin contact or shared items.

Scabies is a global issue, unaffected by socioeconomic or geographic factors, and thrives in environments with close body contact, such as childcare settings where children frequently interact physically. Therefore, proactive communication with families regarding preventive measures and treatment protocols is vital in managing scabies outbreaks effectively.

Environmental

The mites responsible for scabies can survive two to three days away from human skin, highlighting the importance of thorough cleaning and disinfection measures. Items that cannot be laundered should be kept from body contact for over 72 hours to ensure decontamination. Unlike head lice, which necessitate sealing items in plastic bags for two weeks, or bed bugs, which can persist for up to a year, scabies mites have a shorter survival period of at least 72 hours. Therefore, meticulous vacuuming, damp mopping of floors, and cleaning of furniture, including removing cushions and vacuuming underneath them, are essential steps in pest control.

Embracing a culture of general sanitation, aligned with Integrated Pest Management (IPM) principles, is crucial in early childhood environments. Regular washing of bedding is imperative, ensuring families are vigilant in laundering items taken home. Cots and blankets should be separated, and each child's belongings should be labeled and stored in individual cubbies to prevent cross-contamination. When arranging cots, maintaining a distance of about two feet between them is recommended, with adherence to the "Caring for Our Children's Standards for Health and Safety," advocating for a head-to-toe orientation to minimize contact between children.

Maintaining separation and cleanliness extends to hats and coats, emphasizing frequent cleaning practices, particularly in the bathroom and toileting areas, which should be cleaned daily or more frequently if contamination is suspected. Encouraging regular handwashing with soap and running water for children and adults is paramount, along with the daily washing of mouthed toys and disinfection between each child's use. By implementing these measures diligently, the risk of infestations such as pinworms and scabies can be significantly mitigated in early childhood settings.

Conclusion

The resources utilized for this information include the Centers for Disease Control, which provides comprehensive guidance and visual aids for identifying pests in early childhood education programs. Additionally, "Caring for Our Children: National Health and Safety Performance Standards" is highly regarded as the top reference for early childhood education, offering a wealth of information on various topics, including pinworms and head lice. The Environmental Protection Agency also offers valuable pest management and control strategies information. These resources collectively contribute to developing effective protocols for maintaining a safe and healthy environment in early childhood settings.

References

Centers for Disease Control and Prevention. (n.d.). CDC.gov. Retrieved from https://www.cdc.gov

Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs. (n.d.). Retrieved from https://nrckids.org

Environmental Protection Agency. (n.d.). EPA.gov. Retrieved from https://www.epa.gov