Your Favorite School Nurse

To Ice or Not To Ice

To ice or not to ice? This is an issue I face daily as the school nurse. The little ones get bumped and boo-boo’ed and the first thing everyone thinks is “oh dear, you need ice for that pain!”. But when is it appropriate to give ice for an injury and when is it not appropriate?

First of all, why is ice even used? When you get an acute (new) injury, your body is programmed to start an inflammatory response – your blood vessels dilate (get wider) drawing more blood to the site of the injury to try and heal it. This creates redness, heat, swelling, and often pain. Your body may also create a bruise – some of the tiny blood vessels break from the injury and a little blood leaks out under the surface of the skin and creates that bluish/greenish/purplish bruise (ouch!). The purpose of the ice is to help reduce this inflammatory response. Ice will help reduce swelling, reduce the appearance and pain of bruising. Ice can also slow bleeding a bit by helping the blood vessels shrink down again.

Ice is best used when there is an injury such as a twisted ankle (or other areas) that is swelling, a head injury that includes swelling, or any injury that produces swelling, bruising and pain. Pain alone does not mean ice is needed. Ice is also used for overuse injuries (think baseball pitcher, athletes), also for injuries like back and neck strain or tendonitis type issues (issues that most kids don’t have to deal with).

Ice should be used within the first 48 hours of the injury occurring. It should be applied for 15 to 30 minutes, three times a day. Always wrap ice packs in a towel or cloth of some sort to prevent skin injury from the ice.

All of this being said, brings me back to my original question: should we ice or not? In an elementary school setting the short answer is “probably not”. In general, the minor injuries that happen in elementary do not require ice. Bumped elbows on desks, slaps, thrown pencils, thrown food, trips, and bumps (why does everyone hit their heads on the bathroom door?) do not require an ice pack and a 15-minute time-out. Yes, sometimes an ice pack makes the “big boo-boo” feel better along with the caring and attention from a grown-up and that’s ok and expected with these little ones who are away from their caregivers during the day.

Big injuries that occur less often such as fights involving closed fist punches, fell while running or playing, heads with visible bumps, twisted ankles or knees, or any kind of injury that produces swelling and/or a bruise all warrant an ice pack and a time-out. Injuries that happened at home or last week that “still hurt” do not require ice. The ice will not serve a purpose in that situation.

More often though, what I encounter is students who are erroneously instructed that “ice will heal the injury no matter what it is”. The students have a pain for whatever reason and they think that ice will solve it. Sometimes the school nurse (or teacher) can see that the student is upset by the pain and perhaps will be able to get on with their day a little better with the application of some ice, but for a lot of these “injuries” children (and adults too, honestly) need to understand that sometimes we have a pain or a discomfort but it does not need to be addressed because it will go away. Many times I have said to the kids after hearing a complaint that they have a bumped body part “yes it hurts, but it will stop hurting” because that’s what our bodies do. They hurt for a short time but then it goes away.

It’s a difficult balance to decide which is more important for the kids: do they need the attention of seeing the nurse and receiving an ice pack or do they need to learn to tolerate discomforts and move on? The majority of the time, the students need to remain in their class and participate in learning. There is nothing wrong with the expectation that they will move on from minor bumps and boo-boos without intervention.

When all else fails, a little “boo-boo cream” (aloe or body lotion or plain water in the fridge labeled “boo-boo away”) might just do the trick!

Your Child Has Asthma: What the School Nurse Needs You to Know

So your kid has asthma, and they go to school. Here’s what the school nurse needs you to know about that:

1. I need you to understand what asthma is and isn’t. Asthma is not a cough or a cold. Asthma is not being out of breath from physical activity. Asthma is a big deal.

Asthma is an inflammation and swelling of the small tubes within the lungs that help a person exchange oxygen into their blood. Without good oxygen exchange, our brains and bodies can not function very well. It can be very serious, even deadly, if not managed.

Asthma is caused by a few things:

Genetics: a lot of the time if a mom or dad or blood-related family member has asthma it can be passed on to kids. You can’t stop it from happening but you can manage it. Some kids grow out of it as they get older, some do not.
Environment: Living in a city with lots of smog and bad air quality (such as our lovely City of Brotherly Love) can have a harmful effect on breathing and lead to asthma. Very cold weather or very hot weather can also cause asthma flares or attacks.
Bad respiratory viruses in kids: Kids and babies who get RSV or other serious respiratory viruses can often develop asthma. It’s not a guarantee but it happens.
Allergies: Asthma is very similar to an allergic reaction. Many allergens can cause an asthma flare. The same chemical that our body makes that makes you itchy or get hives with an allergy (called Histamine) also can cause a person with asthma to have their lungs tighten and cause an asthma attack. Some people have allergy-induced asthma meaning that when they are exposed to a “trigger” such as pollen or animal hair, they have an asthma attack.
Smoking: I could include smoking under environment or allergy topics but I wanted to single it out. A child who is exposed to second or third-hand smoke (cigarettes, weed, or even fireplaces) will continue to have asthma symptoms and have a very hard time improving. If you are a smoker and your kids have asthma – please consider quitting as soon as possible.

2. I need you to understand how to deal with your kid and their asthma both at home and at school.

Take them to the doctor. They need to be evaluated regularly to make sure they are doing ok and have all the right medications even if you think they seem fine.
Get all the medications they are prescribed. The doctor prescribes the medications for a reason and that’s because they think it’s the best thing to help your child. I know that prescriptions can be expensive but there are ways to get them. If you need help, ask your doctor or school nurse about applying for assistance or finding low-cost options for paying for medical care.
Tell your child’s school nurse! I have encountered quite a few students who apparently have asthma but I never received a health form, medication form, or any information indication that they have a health issue. If your kid has an asthma attack at school and I didn’t know they had asthma, it’s kind of a big deal. Send in the forms! And please please please do NOT stick an inhaler in your kids pocket or backpack and not tell the nurse or the teacher or both! More than once I’ve had a kid show up with an inhaler that wasn’t theirs or they didn’t know how to use correctly or they thought it would be a good idea to share with their friends and this is dangerous! Any medicine at school must be monitored by an adult and go through all the proper procedures for your child’s safety.
Communicate: If your child is sick with a cold and needs extra support, tell the nurse (and the teacher). If they are having a flare and need their inhaler regularly until they are better, tell the nurse and teacher. If they just need their inhaler before gym class or recess, let the nurse and teacher know. Help us help you – we know nothing if we aren’t told.
Provide a rescue inhaler (Albuterol, Ventolin) to the school nurse. In my district, we do not provide medication such as rescue inhalers, it is the parent’s responsibility to bring the medication to school along with the signed, filled out order forms.
Listen to your kid. When they say that they feel like their chest is tight, that they feel like they can’t breathe, you hear them wheezing (a whistling sound when they breathe), they are coughing a lot, or even vomiting sometimes – take them seriously.
Clean: This might seem obvious but having lots of dust or mold or pet hair around can trigger asthma or make a kid keep having flares. Try to keep dust and mold away. Try to keep things like carpets at a minimum (they gather a lot of dust).
Eliminate things in the air: things like fragrances, scented candles, essential oil diffusers, or smoke are irritants and can make asthma worse.

3. I need you to know what asthma looks like and feels like. It can be very mild or become severe quickly. Take a drinking straw (oh wait, I’m not supposed to promote straws… find a paper straw!) and try breathing through it. See how hard it is? that’s how a person with asthma feels during an attack.

Hard to breathe: When your kid looks like they are breathing fast, shallow, or tells you it’s hard to breathe.
Wheezing: That whistling kind of noise that someone makes when they breathe in or out.
Coughing: a dry constant cough, not so much congested.
Eczema: not everyone with asthma has eczema and not everyone with eczema has asthma but they do often go hand in hand. Both are chronic inflammatory issues often caused by the same things. Some kids who get an eczema flare may also have more trouble with their asthma too.
Retractions or nasal flaring: This is a sign that the child is having trouble sucking in air. You will see them flaring their nostrils, possibly the area at the base of their neck sucking in as they breathe, sometimes they have the area around the bottom of their ribs sucking in as well. This is a big deal – call the doctor right away!
Vomiting: sometimes kids with asthma start vomiting as a sign of an attack. Look for other symptoms if your asthma kid is throwing up.
Leaning over or “tri podding”, pursed-lip breathing: sometimes we instinctively put ourselves in positions to help us breathe when it seems hard. When you see your asthma kid leaning over or blowing through their lips like they are whistling, they are likely having a hard time breathing and should be addressed.
Panicking: A person who has asthma and is having an asthma attack may start to panic when they can’t breathe. The lack of oxygen plus the fear of not being able to breathe causes this. Help that person stay calm while you get their medicine. Have them sit upright, focus on you and concentrate on breathing slowly and deeply (they may be limited on “deep” breathing but the focus and the slow breaths help).
Blue lips, blue skin: Call 911 and get albuterol right away. If someone is blue that means they aren’t getting oxygen. This is a major emergency.
Not waking up or very drowsy/passing out: Call 911 and get albuterol right away! This also means this person is not getting enough or any oxygen and needs emergency help right away.

4. I need you to know what the medications are and what they are used for. Rescue inhalers are not the same as daily maintenance inhalers. There are also various pills and nebulizers that can be prescribed. It’s really important to know what they are and how to use them. I’m not listing every medication but these are some of the ones you will see more often for kids.

Albuterol inhaler (also known as Ventolin or Proventil, ProAir, Xopenex): this is a fast-acting rescue inhaler. When your child is having an asthma attack this should be the first thing you go for. The purpose of Albuterol is to quickly open up the tubes in the lungs so more air can pass through. Generally, they are used every 4 hours but during an asthma flare, your doctor may give you other instructions for using it. Your school nurse needs to have this inhaler at school for your child in case of an emergency.
Flovent, Advair, Pulmicort, Qvar: These are inhaled steroids and combination medicines. These are used as daily maintenance medications or maintenance during a flare. These do not relieve coughs or sudden onset symptoms like a rescue inhaler. These are usually kept at home and used once or twice a day as prescribed by a doctor.
Singulair: It’s an allergy medicine but it helps with those inflamed, swollen lungs. remember when I was talking about the Histamine causing allergies which can make asthma worse? Singulair helps stop that Histamine from making asthma bad. It’s a tiny pill you take once a day. Not all doctors prescribe this but some do, it depends on what is causing your child’s asthma.
Prednisone: A steroid medicine that helps when someone is in an asthma flare. Steroids help take away the swelling and inflammation in the lungs. Prednisone is usually given as a pill or liquid medicine, prescribed by a doctor for a short period of time during a bad flare-up. Be aware – Prednisone can make kids super crazy! Understand that they may have bad behavior and lots of energy when they are on this.
Nebulizer Machine: This is just a different way to give some of the medicines like Albuterol or Inhaled steroids. The nebulizer uses little capsules of the same medicines but you use a mask or mouthpiece to breathe in the cool medicated steam for 10-15 minutes or so. Personally, I like nebulizer machines better because I feel like they work better but the inhalers are quicker and easier to carry around for emergencies. You can bring this to school if you wanted to but you would have to follow the same rules as inhalers – provide the machine and all its parts, and the medicine, and the doctor’s form ordering it.

5. I need you to know what happens at school when your kid has asthma. It’s not universal, different schools and districts have different policies on medications and health care management.

Your job as the parent: you will provide the health forms and medication orders along with the medication that is needed at school. You will let the nurse know about any changes or needs for your child.
My job as the school nurse: If your child is scheduled to use their inhaler before gym or recess I will give it at the correct time.
If your child comes to me and says they feel like they are having chest tightness or cough, or other asthma symptoms I will evaluate them. If they are wheezing or exhibiting signs of distress I will give them their inhaler and probably call you. If they are not wheezing and don’t appear to be in distress I will take non-medicine measures first like having them sit down and rest, drink water, and deep breathe. If they don’t feel better then we will try the inhaler.
If I do not have an inhaler for them and they need it then I will call home and request that a parent bring their inhaler or pick them up and take them to the doctor or hospital (depending on how much distress the child is in). If I am unable to contact a parent or family member and the child is having an asthmatic emergency I will call 911 and your child will be transported to the nearest emergency room for treatment.

TL;DR

Know what asthma looks like in your kid. Know what the meds are for and when to use them. Understand that asthma is a very serious issue that can lead to death if not managed well. Communicate with your child’s school nurse and teacher about their asthma and provide the appropriate medicine and paperwork required by your child’s school in order to best care for your child.

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Your Kid Has Lice: Updated 10/16/23

So you’ve received the dreaded phone call from school: your kid has head lice. After you have gotten yourself together and stopped scratching your own head (phantom lice, I totally get it), I can give you some tips and info.

Lice are icky, itchy, no fun all around and sometimes expensive to deal with. They do NOT, however, transmit any diseases.
Lice are also NOT an indicator of how clean or dirty a person or their environment is. Lice actually prefer to hang out in clean hair over dirty hair.
Lice are transmitted by direct contact with someone who already has LIVE lice in their hair – this includes touching heads, sharing hats, hairbrushes, hair accessories, and sometimes scarves or pillows.
They are NOT transmitted by flying, hopping, or being in the same room as a person who has them.
Lice can only survive for about 24 hours when not on a human host. That means that once the bugs jump off the person’s head and go on a carpet or a sofa, they won’t live more than a day or so.
A louse can lay 3-5 eggs a day and the eggs take about 7-10 days to hatch. Then they take another 7-10 days to be mature enough to lay their own eggs. It’s a whole cycle.

So what do we do now that we got the news? There are quite a few things you can do for lice, some are just things to help but are not proven.

The number one thing you’re going to do is get a proven (proven meaning safe, studied, and approved as a “medication” on the market) store-bought lice treatment shampoo. You can go to whatever store is convenient (Walmart, Target, Rite-Aid, wherever) and find Rid, Nix, store brand lice shampoo, or there are a bunch of products on the shelves. The effective shampoos usually contain Permetherin or Pyrethrin (I know, it’s a chemical but it’s kind of necessary). There are a lot of products at the store that have non-chemical ingredients or claim to be “preventative” but they are not proven to work effectively.
Alternatively, if one needed to, you can go to a local health clinic, Emergency Room, or your pediatrician and they can prescribe a prescription shampoo that can be paid for with medical assistance or health insurance (if you have that).
After you’ve treated with the shampoo, the next most important thing to do is to go through and comb out those nits (eggs)! This is a very important step because if you leave the eggs in their hair they will hatch and re-infest the hair so all the treatment will be for nothing. A lot of the lice shampoos come with little metal or plastic lice combs to use. There is a cool product called the Liceguard RobiComb that uses a little bit of electricity to zap the nits and live lice – it’s NOT a proven treatment but it’s kind of cool and doesn’t hurt (you can get that here: https://amzn.to/2RqrGAv). You will start at the hairline at the back of the neck, take small sections of hair and carefully comb through removing the eggs with the comb and/or your fingers. Go all the way through the entire head in very small sections. It might take a while but it is the only way!
You should re-treat in about a week because the eggs that didn’t get removed will hatch.
It is recommended to examine everyone in the home for the presence of live lice and/or nits and treat if lice are present since people living in close quarters are likely to all have lice together. There is no need to treat someone who does not have any notable lice or nits but it is wise to recheck everyone after about 10 days or so to make sure.

After the people are treated you still have to contend with the house as everyone will just be re-infested if you don’t address the house.

Wash and machine dry all bed sheets and linens from the person with lice that were used within 3 days before treatment. Use the HOT water cycle (130 degrees) for the wash and dry with the high heat setting.
Anything that can’t be washed (stuffed animals, certain clothes, etc) SEAL into a plastic bag for at least 2 weeks so the lice are killed. or have dry cleaned.
Soak combs and brushes in very hot water (130 degrees) for 5-10 minutes OR throw them out and get new.
Vacuum, vacuum, vacuum. Vacuum furniture and carpets daily. The lice will get sucked up into the vacuum and die because they don’t have a person to feed on.
It is not necessary to call in companies that will get rid of the lice for you but you are welcome to if you have the means to do it.
It is not necessary to do fumigation sprays or bug bombs in the house since they are not only toxic to humans and pets but also costly and unnecessary.
https://www.cdc.gov/parasites/lice/head/treatment.html you can refer to this page about lice from the CDC for further info as well.

Many people are interested in alternative solutions to using chemicals on lice, which I totally get! There are a few treatments and ideas that you can try out. I will note that these aren’t scientifically or medically proven to be effective as they have not been studied adequately, but plenty of people have success if done correctly. It is also important to note that using alternative treatments should be done with the knowledge that there are potential side effects such as allergic reaction to products, or introduction of infection due to non-medicinal products being used. It is NOT recommended to use these methods as the only means for treating lice.

Mayonaise: Literally get a jar of mayo – any kind will do. Slather it all over the person’s hair and put on a shower cap. Leave it all night and wash it out in the morning. The mayo is thick and will suffocate the lice. You will still have to comb through with the lice comb to remove all the eggs because the mayo will not get rid of them.
Coconut oil, olive oil, Anise oil, Vaseline (ew!): It’s the same as the mayo. Maybe a bit more expensive though.
Tea Tree Oil: Put drops of tea tree oil on the scalp with a shower cap on and leave it overnight. Wash it out in the morning and comb out all the eggs. There are a lot of products containing tea tree oil that you can use for preventative measures (although not proven medically, many people swear by it!). Be wary though, if you haven’t used Tea Tree oil (or essential oils in general) on the person in question the possibility exists of an allergic reaction or and contact reaction which could be uncomfortable and dangerous. Most essential oils do require a dilution via carrier oil or even water as they can be irritating if used undiluted. Use with caution.
UPDATE: Something I learned recently as a home treatment for head lice is Diatomaceous Earth! According to the website diatomaceousearth.com “Diatomaceous earth can also be used as chemical free and safe treatment for head lice. Diatomaceous Earth causes the insect to dry out and die by absorbing the oils and fats from the insect’s exoskeleton. Its abrasive structure speeds up the process. Try it by mixing one teaspoon of Diatomaceous Earth with tea tree oil. Massage this into your scalp and leave it in your hair overnight. Rinse in the morning and brush with a lice comb. Make sure to repeat this for a couple of days. According to the Mayo Clinic, “When used topically, tea tree oil is generally safe and might be helpful in treating acne and other superficial skin infections.” “When used in combination with lavender oil, tea tree oil has been shown to be effective at treating lice eggs.” PubMed also published a research study that showed, “Tea tree and peppermint caused the most repellence, and tea tree and lavender prevented some blood feeding on treated skin.” Another research finding from PubMed also showed great results on the effectiveness of tea tree oil.” You can find it here.
Call in the professionals: There are a few companies that will come to your house and do it all for you! Hair Heroes http://www.hair-heroes.net/, Lice Lifters https://www.thelicelifters.com/, and Lice Doctors https://www.licedoctors.com/ are a few with really good ratings. This can be costly and is not necessary but if you have the means and don’t want to do all of the treatment yourself you can definitely give them a call.

There are rules in my district regarding the handling of lice at school that come from the Department of Health. You can check with your school nurse on your school’s policy on handling lice.

Because lice do not pose a health hazard, students may remain in school until the end of the day after lice have been noted. The parents will be notified by letter and phonecall (if possible).
The students can not return to school until they have been treated for the lice and the parent brings proof of treatment AND the student checks out as clear by the nurse. Proof of treatment can be the box and the receipt from the purchase.
We no longer check all the students in a class when one student is noted to have lice, nor do we send home letters to every student in the class about it. This not only brings shame and potential bullying to the student who has lice but it also isn’t necessary.
The students are permitted to be in school with eggs in their hair as eggs are not transmittable but the parent should still carefully remove them as soon as possible before they hatch and cause a new infestation. The parent of the student will be notified if eggs are seen.
If you notice lice on your child at home, you should treat them as soon as possible. Please make sure to inform your school nurse and your child’s teacher.

TL;DR

Lice are not that bad! They may be yucky but they don’t cause any major issues. Treat them with lice shampoo. Alternative treatments may or may not work and have the potential for unwanted effects. Clean in your house for lice in addition to treating the people. Check the whole fam at the same time and treat anyone with lice so it doesn’t keep coming back. COMB OUT THE EGGS!!! Godspeed.

For school nurse resource please visit www.identify.us.com for all the best info on all things buggy.

Here is the newest guidance regarding management of head lice, an excellent read! https://onlinelibrary.wiley.com/doi/epdf/10.1111/ijd.15096?fbclid=IwAR1MX6_MBZgYSoNzdf8jTAc2LHg–Cf90dcsd8KYrAAfQWFfse_stOxnGDM

And another great article regarding head lice management: https://www.pediatricnursing.net/ce/2016/article4005226235.pdf?fbclid=IwAR0h49Y2jmqAkCev6sszWZtzq2TbUCFeRuQb5A6i5uw2ARgKkc8-OUwrMrQ

https://www.diatomaceousearth.com/blogs/health-benefits/the-beauty-benefits-of-diatomaceous-earth#:~:text=Diatomaceous%20earth%20can%20also%20be,structure%20speeds%20up%20the%20process.

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