The 2-Hour Rule, Part Deux: A Cautionary Tale

After reading the comments I received from my post on formula prep and handling, I felt like I did this one time in second grade when my favorite teacher caught me passing notes: Embarrassed, guilty and like I learned a really valuable lesson (yeah, I admit it, I was a total sycophant in school).

The embarrassment came from me realizing that while I may be the Fearless Formula Feeder, I am also in many ways the Completely Clueless Formula Feeder. The irony is that I know a good deal about breastfeeding – but not all that much about bottle feeding. Some of you guys know FAR more than I do.

The guilt came from me realizing that I have essentially been risking my child’s health for the past few months, due to a disbelief in the importance of proper formula etiquette.

The really valuable lesson came from me realizing that as an educated, research-savvy former editor of a parenting magazine, it is scary as hell that I knew as little as I did. Even scarier, practically all I do all day is study, write about, and discuss infant feeding issues.  I have now formula fed two infants, and at no point did a medical
professional tell me ANYTHING about what water to use, or why I wasn’t supposed to use a bottle after a certain amount of time.

I took several classes on breastfeeding; I read multiple books on breastfeeding; I had paid professionals helping me breastfeed; I had access to a free group, run by the same paid professionals, which would support me in my breastfeeding endeavors.

When I became a formula feeder, I had a few sentences on the back of a formula can, with the most prominent message being “use as directed by your doctor.” My doctor directed me to breastfeed, and when I couldn’t, had no advice to give about proper feeding. The underlying message there: Your baby is already a lost cause, so what’s the point?

There is NO excuse for us not to be given complete, thorough and factual information on infant formula preparation and usage. Neglecting to give useful information about formula feeding is not going to raise breastfeeding rates; it’s going to put babies at risk. It’s a dumb, juvenile and punitive move by the powers that be.

Sure, there are some “guidelines” printed on the back of the formula canister. But if in one breath, parenting gurus like Dr. Sears are telling us that formula companies are the devil, and that we shouldn’t believe anything these companies say; and then in the next they are dismissively suggesting we can get all the information we need from this same devil… well, that’s just obnoxious. Obnoxious and dangerous.

One of the consistently proven “risks” of formula feeding even in affluent nations with good water supplies is a increased risk of gastroenteritis. I wonder if this could possibly be due to improper formula use rather than the formula itself? For example, how many parents were doing what I was doing, and figuring that leaving formula out for a few extra minutes couldn’t hurt? Or what if they didn’t know they were supposed to boil the water first to kill any bacteria – even if they lived in a place with “safe” tap water? Or that purified water wasn’t necessarily good enough? I’m not even talking about major, life-threatening types of stomach illness, like the necrotizing enterocolitis so prevalent in NICU populations. I’m talking minor bouts of diarrhea that give formula fed babies the reputation for being more prone to gastrointestinal bugs.

This has got to stop. It’s not fair that formula feeding parents need to get their information online from either breastfeeding advocates with an axe to grind; formula companies primarily interested in profit; or misguided formula feeding bloggers who know far more about breastfeeding than they do about the “rules” which actually apply to their fan base.

So – that said, I’m implementing a new feature on the blog. Twice a month I will feature posts on the actual mechanics of formula feeding. I will be honest with you when I don’t know the answer to something, and we can do what we did with the post that started my little revolution… we can share our info, and piece together the real story. Feel free to email me ( with the specific things that are puzzling you, and I will do my best to crack the case.

And now, back to the subject at hand. The Two-Hour Rule, Redux. I made some misleading claims in my first post on this subject that I want to retract and/or clarify.

First….I was somewhat correct in my original post; breastmilk is subject to similar laws of nature and without a doubt, can be contaminated if left out too long. The difference between the two substances is that breastmilk at least begins as a sterile substance. Reconstituted formula is NOT sterile, and in fact there have been cases where  Enterobacter sakazakii has been found in unopened cans of formula. Once the bacteria is in there, it can easily grow and thrive. For example, this bacteria is of primary concern in the NICU, because it can cling to surfaces like feeding tubes; if these tubes are not properly cleaned, babies become infected. But even at-home devices like formula pitchers are breeding grounds for bacteria. I never used one of these for FC (seemed like an annoying extra step) but our formula pitcher has been a lifesaver with Fearlette, who needs a strange brew of thickened hypoallergenic requiring insane measurements that would be difficult to do at a moment’s notice – especially a moment around 3am when I’m half awake, and naturally clumsy.

It’s nothing to stress over too much, but for younger babies, I do think it’s important to clean all formula-related equipment carefully. I swear by those microwave sterilization bags sold by a really famous breastpump maker who rhymes with Shmedela…you can just throw all your bottles/disks/rings/caps in there, stick it in the NukeBox, and zap. You’re done.

Water-wise, to be totally safe, you should boil all your water, whether it be from tap or bottle; let it cool, and then mix with formula. However, this isn’t very practical, and I can tell you that a few pediatricians I’ve spoken with say that it is perfectly okay to use that Nursery Water stuff (the flouride is a different issue, but we dealt with that in another post) or distilled water, as long as your baby is full term, and healthy; eventually, depending on where you live, tap is kosher, too. But as much as I hate to say this, if you can afford it  – spring for the ready-to-feed infant nursers for those first few weeks. I know they are pricey (another reason I hope that they don’t outlaw the hospital sample bags, because this is usually what is in them) but those tiny disposable bottles truly are your safest option. After the first few weeks, you can switch to powder and use boiled tap water or bottled, distilled water.

As for leaving formula out, I did read a study (thanks to Becky, who gets the promised gold star) that found that the longer formula was left at room temp, the more bacteria grew. This does not mean that the bacteria level found would necessarily be enough to make your 6-month-old sick from one crusty bottle of formula milk, but there are facts, and then there are real-world applications. We pick and choose our battles, but we should be informed enough to be able to decide which fights to wage.

I will tell you that since I started researching these things a few days ago I have become super anal about not allowing Fearlette to snack on an older bottle. I just use my (well-cleaned) formula pitcher so I can pour small amounts at a time; this way we don’t waste much of her liquid gold (aka Alimentum), but she’s also not nursing a bottle potentially full of microscopic bugs. Do I honestly believe that she is going to get sick from doing this? Probably not. But I know the inconvenience is worth avoiding the risk, which is apparently a documented risk…. and I also wish someone had given me more evidence-based advice on these things, because it would have at least made me understand why we have to follow these terribly annoying rules.

Some other interesting things I learned from FFF readers over on the Facebook page:

Jennifer suggested mixing formula “with boiled water that is still hot. That will not only kill bacteria that might be in the water but also ones that might be in the formula. Of course, then you have to let it cool before feeding it or refrigerating it, at which point it can be contaminated with bacteria just like any other food.” But then  Ella pointed out that “recommendation in the UK is to NEVER mix formula and water and then refrigerate,” but rather to “boil water, keep in fridge, then mix with powder when needed”, she then mused that “in France…you mix the powder with bottled water- Volvic or Evian, the others being to high in I can’t remember what- at room temperature, so no boiling involved at all. No one seems to agree on what to do…” 

Methinks I have my first homework assignment…

Suzanne Barston is a blogger and author of BOTTLED UP. Fearless Formula Feeder is a blog – and community – dedicated to infant feeding choice, and committed to providing non-judgmental support for all new parents. It exists to protect women from misleading or misrepresented “facts”; essentialist ideals about what mothers should think, feel, or do; government and health authorities who form policy statements based on ambivalent research; and the insidious beast known as Internetus Trolliamus, Mommy Blog Varietal.

Suzanne Barston – who has written posts on Fearless Formula Feeder.

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