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Aim: To evaluate the impact of promotion of exclusive breastfeeding on infant health in Guinea-Bissau, West Africa, where mortality rates are high, breastfeeding is widely practiced but exclusive breastfeeding is rare. Method: At the Bandim Health Project in Guinea Bissau, West Africa, a birth cohort of 1721 infants were randomized to receive health education: promotion of exclusive breastfeeding for the first 4–6 months of life according to WHO recommendations at the time of the study. All children were followed from birth to 6 months of age. Results: Introduction of both water and weaning food was significantly delayed in the intervention group. However we found no beneficial health effects of the intervention; there was no reduction in mortality in the intervention group compared with the control group (mortality rate ratio: 1.86 (0.79–4.39)), weight at 4–6 months of age was significantly lower in the intervention group (7.10 kg vs. 7.25 kg; Wilcoxon two-sample test: p = 0.03). There was no difference in diarrhoea morbidity and hospitalization rates. Conclusion: Although mothers were sensitive to follow new breastfeeding recommendations, it had no beneficial impact on infant health in this society with traditional, intensive breastfeeding. There seems to be little reason to discourage local practices as long as there are no strong data justifying such a change. [ABSTRACT FROM AUTHOR]