Online education for WIC professionals: Teaching child development to extend breastfeeding duration

Details of Pilot Study

This pilot study was done to assess the impact of HUG Your Baby’s (HYB) Roadmap to Breastfeeding Success training with WIC New Mexico. A total of 138 New Mexico WIC peer counselors, IBCLCs and dieticians completed this course from fall 2016-fall 2017. The study was approved by the IRB at University of North Carolina at Chapel Hill.

Though education includes the acquisition of important knowledge, current health research concludes that effective education must also address how a program changes behavior. The Theory of Planned Behavior Model suggests that a person’s intention to change motivates behavior and behavior change (Watkins, Dodgson & McClain.)  Other literature concludes that a professional’s confidence to provide care contributes to the care they go on to offer. The purpose of this study was to identify a pre- to post-course change in participants’

  • Knowledge of a baby’s behavior as it relates to breastfeeding support;
  • Intention to teach about how child development impacts breastfeeding and,
  • Confidence to provide this care.

Participants (N = 138) rated their professional experience in lactation support as follows:

  • 52% having 0-2 years
  • 16% having 3-5 years
  • 12% having 6-8 years
  • 7% having 9-11 years
  • 13% having 12 years or more


Data for this study were collected from three sources: 1) a nonexperimental pre- and post-test (with seven multiple choice and three true-false questions); 2) a ten-question, self-report survey of intention and confidence; and 3) a four-question course evaluation. Participants were asked to score the survey and course evaluation using a four-point Likert scale. Data were collected electronically by Digital Chalk, a web-hosting platform.

A total of 138 New Mexico WIC peer counselors, IBCLCs and dieticians completed this course from fall 2016-fall 2017. Participants were chosen by WIC supervisors and given time to complete this course as part of their required continuing education. Results are summarized below.

 Study Results

Scoring of Intention and Confidence Survey and Course Evaluation:

Pre- and post-test questions were scored as correct or not. Participants responded to pre- and post-course intention and confidence surveys, and to the course evaluation, on a four-point Likert scale. The answer was scored positive if the participant responded with “Strongly Agree” or “Agree” and scored negatively if a participant responded with “Disagree” or “Strongly Disagree.”

Knowledge Results: N=138

  • Pre-test knowledge scores ranged from 20% (1 person) to 100% (1 person) with a mean score of 66%. The median score was 70%.
  • 57% participants passed the pre-test by scoring 70% or more
  • 100% passed the post-test. (90% achieved a passing score on the first attempt; 10% passed on a retake, which is permitted by the online program
  • Post-test knowledge scores ranged from 70% (21 person) to 100% (38 person) with a mean score of 87%. The median score was 90%.
  • Greatest improvement occurred in four questions: Touchpoints theory, the impact of surges in development on breastfeeding, normal crying patterns, and sleep cycles. (See Chart 1.)

Chart 1

The knowledge test contained three subject areas:

  • Assess understanding of feeding cues and evidence breastfeeding is going well.
    • Question1 Identify an example of an early feeding cue in a newborn.
      • Answer – Begins to wiggle and squirm.
      • Correct: pre-test 85%, post-test 99%
    • Question 2 Which information about a two-week-old breastfeeding baby indicates the need for more support and education to ensure adequate nutrition?
      • Answer – Baby has one stool a day.
      • Correct: pre-test 52%, post-test 65%
    • Question 7 A one-month-old breastfeeding baby is gaining one ounce a day. Over several days he drops from six stools a day to one stool. This change indicates a need to increase calories.
      • Answer – False
      • Correct: pre-test 77%, post-test 88%
  • Assess impact of a surge in child’s development on baby’s eating and sleeping.
    • Question 3 According to Dr. T. Berry Brazelton’s Touchpoints theory, a surge in a baby’s development temporarily improves a baby’s eating and sleeping patterns.
      • Answer – False
      • Correct: pre-test 33%, post-test 84%
    • Question 6 A full-term baby typically increases her daily crying . . .
      • Answer – at two weeks old.
      • Correct: pre-test 46%, post-test 89%
    • Question 8 Breastfeeding is well-established in a six-week-old baby. Every hour during the night he smacks his lips, briefly opens and closes his eyes, wiggles, and whimpers a bit. Which statement is most ACCURATE?
      • Answer – This baby may return, on his own, back to deep sleep.
      • Correct: pre-test 63%, post-test 91%
    • Question 9 A four-month-old baby is increasingly distracted during breastfeeding. This behavior indicates that the baby needs to wean.
      • Answer – False
      • Correct: pre-test 96%, post-test 97%
    • Question 10 A one-year-old baby, on the verge of walking, is suddenly waking more frequently at night. The WIC counselor is correct when she tells the mother that the baby needs more nighttime calories.
      • Answer – False
      • Correct: pre-test 51%, post-test 83%
  • Assess understanding body and behavioral signs of over-stimulation.
    • Question 4 A four-year-old shakes a rattle for his one-week-old sister. The baby turns away from her brother, gets pale in the face, and is a bit jerky with her movements. Which statement BEST describes this baby’s behavior?
      • Answer – The baby’s behavior indicates a response to too much stimulation.
      • Correct: pre-test 88%, post-test 99%
    • Question 5 Which of the following is a sign of over-stimulation in a baby whose mother is bringing him to the breast?
      • Answer – Baby squeezes his eyes shut.
      • Correct: pre-test 72%, post-test 92%

Test results suggested that participants in this pilot study had traditional lactation knowledge, such as understanding infant’s early feeding cues. However, they lacked information about how a child’s development might impact breastfeeding and about normal crying patterns and sleep cycles in infants. Interestingly, these pre-test results are comparable to results recently gathered in a multi-site study of faculty and students at Duke, Johns Hopkins, and UNC-Chapel Hill Schools of Nursing (Alden et al., 2018). (See Chart 2 below.)


Chart 2

Intention Results:

Before completing the course an average of 58% of participants rated that they teach this information about child development and breastfeeding. After the course 100% of participants reported they intend to include this information in their teaching. (See Chart 3.)

Chart 3

Confidence Results:

Prior to completing the course an average of 80% of participants rated that they are confident in performing these actions. At the end of the course 100% of participants rated they are confident they can perform these actions. (See Chart 4.)

Chart 4

Course evaluation:

One hundred percent of participants strongly agree or agree that the course as evidence-based; claimed the online format as convenient and easy to use; would recommend this course to colleagues; and, want to use the HUG video and Roadmap handouts with families. (See Chart 5.)

Chart 5

Sample of optional comments about the course:

  • I love the information in the course, it was very interesting and helpful, now I feel more confident to talk to parents about baby behavior and how it can be challenging to breastfeed if they are not aware of the baby’s states and help them gain confidence to continue breastfeeding through their bay’s development surges.
  • I truly enjoyed the stories both from the moms and from Jan. It provided a personal approach that made it more user friendly. I have two children and I believe I could have benefited from a lot of this information. The lullabies were wonderful! 🙂 Thank you!
  • I really enjoyed this online training. It was very informational and unlike other trainings it kept my attention all the way through and was so very informative.
  • I really enjoyed this course! I am looking forward to sharing information about these milestones to pregnant and nursing mothers to help prepare them for changes. Education will lead to better breastfeeding success! Great work putting this together!
  • This was a wonder course and the use of repetition to reinforce the information was very helpful and I feel more confident about my ability to retain and recall the information.

Criticisms/ Suggestions:

  • Two participants requested deletion of the lullabies.
  • One suggested making video clips even shorter.

Problems and limitations:

  • Eight percent of participants experienced minor technical problems and contacted the author to reset passwords, to clarify how to move forward in the course, or to be reminded how to print a certificate of completion. Though initially frustrating to participants, these issues were easily addressed.
  • A research consultant questioned if the way we captured participants’ post-course intention to use material was valid.
  • Because there is no valid and reliable tool that assesses a professional’s understanding of how child development impacts breastfeeding, the pre- and post-tests were developed by the author. This tool has not yet been evaluated to prove its reliability and validity.
  • Data were gathered such that it was not possible to correlate test and survey results with participants’ professional training.
  • Research needs to be done to assess if sharing The Roadmap information with parents actually increases breastfeeding duration.


Efforts continue nationwide to identify barriers to breastfeeding duration and effective interventions to promote it. However, little attention has been given to educating lactation specialists about how a baby’s development (birth to one year) might impact the breastfeeding experience. Misunderstanding a baby’s behavior can cause mothers to add formula or even abandon breastfeeding. Results of this study of New Mexico WIC professionals demonstrate that HYB’s Roadmap to Breastfeeding Success can equip lactation specialists with knowledge and resources to help parents anticipate and prepare for normal, but sometimes stressful, changes in a baby’s behavior and breastfeeding.

A professional’s intention and confidence to provide evidence-based care increases the likelihood that she or he will translate new knowledge into effective parent teaching and support (Watkins, Dodgson & McClain, 2017). Results from this project suggest that online training utilizing family-friendly language, inspiring case studies, and engaging parent videos can enhance professionals’ desire to add pertinent child development information to their breastfeeding support.

Final analysis of post-tests and surveys identified areas where further education might be helpful to WIC professionals. HYB responded to this need by sending a series of six, weekly e-newsletters to New Mexico participants. These E-newsletters utilized a case study, a parent-child video, and age-appropriate information about child development and breastfeeding issues to reinforce information previously shared in the Roadmap course.

Positive feedback about this course inspired New Mexico WIC leadership to recommend The Roadmap to a sister organization, Breastfeeding on the Border. That organization recently enrolled 40 community health workers in the newly created, Spanish translation of The Roadmap to Breastfeeding Success online course and its accompanying handout and Spanish DVD. Data will be collected from this continuing education project, as lactation professionals in New Mexico and the Southwest continue to seek innovative ways to promote breastfeeding duration.


Alden, K., Busch, D., Gingrich, P., Gordon, H., Silbert, J., Tedder, J., & Trotter, K. (2018). Multisite evaluation of a web-based course to help nursing students understand and teach parents about infant behavior. Unpublished raw data.

Watkins, A., Dodgson, J., &McClain, D. (2017). Online Lactation Education for Healthcare Providers: A Theoretical Approach to Understanding Learning Outcomes. Journal of Human Lactation, 33(4), 725-735.

© HUG Your Baby 2018