RELIANCE: Moringa in Lactation and Early Childhood

Introduction: The objective of the proposed study is to assess the impact of maternal moringa supplementation to mothers of breastfeeding infants on milk output, milk composition, exclusive breastfeeding duration, and maternal and child health. This will be accomplished by conducting a randomized, controlled, dietary intervention study enrolling 100 breastfeeding mothers and their newborn infants with four months intervention and two years follow up. The propose design is a cluster-randomized controlled study of 10g dried moringa leaf powder in carrier vs. carrier alone, consumed daily for four months by breastfeeding mothers of term infants. The investigators will continue the intervention for four months and follow-up for 2 years.

Inclusion Criteria: Women must be >18 years of age; ≤ 30 days postpartum; lactating. Infants must be at least 36 weeks gestational age at birth, singleton birth, exclusively breastfeeding at the time of enrollment.

Exclusion Criteria: Women who report regular consumption of moringa in the last month (>1 time weekly) or are unable unwilling to lactate are ineligible to participate in this study. Infants are ineligible if born before 37 weeks of gestational age, have significant congenital disease, are unable to feed orally, or unable to consume human milk.

Overall Design: A randomized, controlled dietary intervention trial, titled The MiLC Study: Moringa in Lactation and Early Childhood.

Recruitment and Retention: Potential study participants will be identified on arrival to their first postnatal visit to the SUNY Downstate Maternal and Child Health Clinics. All eligible participants will be offered enrollment. Participants will be screened by trained research assistants and enrolled into the study with individual or caregiver informed consent and monthly check-ins. Participant follow-up will occur concurrent with pediatric monitoring visits (approximately 2, 4, 6, 9, 12, 15, 18, 24 months) for two years utilizing study staff and study equipment. Follow-up not requiring in-person visits or participants who do not arrive to their scheduled study visit will receive phone call/text communication to obtain study information and to reschedule follow-up.

Randomization: Upon enrollment, participants will be randomized to the intervention group and the control. All members of the study team will be blinded to this assignment until all primary outcomes are analyzed.

Intervention and control: Intervention and control that are validated through an acceptability trial and subsequently through the investigators pilot clinical trial. Moringa leaf powder at 10g/day was deemed acceptable by mothers previously. A repeated acceptability trial in Brooklyn comparing non-dairy milk, water, and other relevant available carriers. The most palatable combination will be utilized for the trial. The control group will receive carrier alone. Moringa at this dose and higher has been used in multiple clinical trials including the investigator's own pilot with no known adverse effects; these are summarized in the systematic review. The investigators think that the carrier alone is the best control for this study. All subjects will be consuming a palatable carrier of approximately equal calories.

Sample collection: The investigators will obtain breast milk samples (~5ml/timepoint) at baseline, 2, 4, and 6 months in a light-protected manner, as retinols and carotenoids are light-sensitive. The investigators will follow protocols piloted in the prior clinical trial. Women will be asked with study staff supervision to perform expression of the whole breast standardized to the early morning. This will occur outside of direct sunlight, and milk samples will be swirled and aliquoted by study staff then stored on dry ice until transport, where they will be stored at -80C. Serum from mothers will be collected at recruitment, 2, 6,and 9 months; infant serum will be collected by capillary sample at recruitment, 4, 6, 12, 18, and 24 months. Infant hemoglobin will be assessed as per usual clinical protocol at 12 months. 24-hour pre- and post-infant feeding weights (test weights) will be collected on sequential days at recruitment, 4, and 6 months. Investigators will provide a validated scale and clear instructions on weights, and request photographic documentation of weight.

Test weights: Test weights will be performed by weights on provided digital scales in the same clothing or consistently naked before and after each feed. This will occur over a standardized 24 hour period at each collection timepoint. Mothers will record the weights in a parent diary and send photos of the weights to the study team.

24-hour dietary recall: Investigators will review the foods and drinks consumed by mothers in the 24 hours prior to each milk sample.

Perceptions of breastfeeding survey and additional information: At each follow-up, the investigators will do the following: • administer a short, structured questionnaire to mothers to assess their perceptions of infant satiety, adequacy of milk production, and concerns about their provision of milk to their infant.

• assess complementary feeding practices (introduction of anything that is not prescribed medication to the infant) and the use of clean vs. unclean water at these timepoints.
• review of maternal and infant infections, diagnoses, and hospitalizations at the time of visit or since the last visit.