Background Optimal exclusive breastfeeding in terms of frequency of feeds per day and lactational support are often not adequately addressed by healthcare providers. This study examined the relationship between the levels of exclusive breastfeeding, frequency of feeding, alternate feeding patterns, health and growth impacts, among 14 weeks old infants in a remote, understudied village in East Africa. Subject and methods This was a secondary cross-sectional analysis of a prospective cohort data. Data of 514 out of the 529 mother- newborn pairs recruited from birth were obtained and analysed at 14 weeks post-delivery in the clinic. Infant feeding patterns and growth were assessed. Mothers were interviewed using the Edinburgh postpartum depression score to assess mental status. Parametric, non-parametric and regression analysis were applied to examine the relationship between maternal/infant characteristics, infant feeding frequency/patterns and infant growth. The results were presented in p-values, Odds ratio and 95% confidence interval. Results 514 infants were examined at the well-infant clinic, 14-weeks post-delivery. Overall, 32 (6.2%), 33 (6.4%), 84 (16.3%) and 87 (16.9%) out of these 514 infants were weight faltering, wasted, stunted and had slow head growth, respectively, based on anthropometry. Only 12 (7.5%) out of these 159 malnourished infants (some infants had >1 type of malnutrition), showed clinical signs of undernourishment. The exclusive breastfeeding (EBF) rate in the infant cohort had dropped further to 83.9% from the previous rates at birth, 6 weeks and 10weeks post-delivery. 106 (20.6%) of these 514 infants were not adequately fed. The complementary feeds offered to the infants in the non-exclusive breastfeeding group included maize/cassava/soya porridge, cow milk and plain water. None was on infant formula. Infrequent feeding was strongly associated with infants in the EBF (OR=2.08; 95% CI 1.04, 4.17; p=0.038) group unlike those in the non-EBF group. Being exclusively breastfed had no significant positive effect on infant growth, probably because it was weakened by infrequent feeding observed in a larger proportion of infants in the EBF group (22.3%) compared to those in the non-EBF group (12.0%). Non-exclusive breastfeeding was significantly associated with increase in maternal depression score (OR 1.2; 95% CI 1.09, 1.32) and overweight infant (OR 1.87; 95% CI 1.02, 3.41). Infrequent feeding was significantly associated with slow head growth (p=0.001), weight faltering (0.021) and wasting (p=0.013). Hence, infants in the EBF group were significantly associated with slow head growth (OR=2.94; 95% CI 1.25, 7.14; p=0.014) and stunting (OR=4.55; 95% CI 1.61, 12.5), probably as a result of infrequent feeding. High maternal depression score was significantly protective against all categories of infant growth faltering (underweight, stunting, wasting and slow head growth). The male infant was 7.66 times (95% CI 4.09, 14.35; p<0.001), 3.28 times (95% CI 1.89, 5.7; p<0.001) and 2.38 times (95% CI 1.07, 5.29; p=0.033) more likely to experience slower head growth, length faltering and weight faltering, respectively, compared to the female infant. Eighty-eight (17.1%) out of the 514 infants had been previously ill before presenting at the clinic; 69 (13.4%) had mild illness i.e. was managed on outpatient-basis; 15 (2.9%) had moderate illness i.e.was hospitalized for ≤7 days; and 4 (0.8%) had severe illness i.e. was hospitalized for >7days. The top 3 most common illnesses observed in these 88 infants were respiratory infections (69.3%), diarrhea (23.9%) and malaria (6.8%). Conclusion Close attention must be paid to male infants, maternal mental health, type of feeds, frequency of feeding and infant growth parameters during the clinic visits. Infant cow milk feeding practices must be strongly discouraged. The stress of frequent infant feeding and lactational challenges can indeed affect maternal mental health, exclusive breastfeeding practices, and subsequently impact infant growth and health outcomes. Providing comprehensive lactational and mental support programs within maternal and child health systems, can empower mothers to overcome challenges and achieve their exclusive breastfeeding goals. KEY WORDS: weight faltering, stunting, wasting, slow head growth, frequency of feeding, exclusive breastfeeding, post-partum maternal depression score, sex, cow milk.

The authors have declared no competing interest.

This study did not receive any funding

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The Health Sciences Research Ethics Committee of the University of the Free State in South Africa gave the ethical approval for the collection of the primary data for the original study- Growth and growth faltering in a birth cohort in rural Rwanda: a longitudinal study with Ethical Clearance Number: UFS-HSD2018/1493/2901.

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