Diane -- how frustrating.  Sounds like this mom is getting plenty of
stimulation.  Makes me nervous that she had the same problem first time round
and ended up needing to supplement a considerable amount.

Some mothers just don't make milk.  Sometimes a history will turn up an
obvious problem, like endocrine difficulties - no stimulation first 48 hours
- surgery - etc.  Sometimes mom will report no breast growth or increase in
firmness during pregnancy or will have an anatomy suggestive of inadequate
glandular tissue (tubular breasts, breasts that appear arrested at an
adolescent stage of development or very asymmetrical breasts).  Sometimes you
can be suspicious if you see little of the typical vascularity of lactation.

Delivery will occasionally give us a hint -- I know it's controversial but I
do see (anecdotally) a link between unusual blood loss (not enough to cause
Sheehan's syndrome) during delivery and low milk supply.  And I do hear my
low milk moms mutter about having always been anemic -- but perhaps this is
coincidental.  No-one is worried about their hematocrit levels although they
are borderline.

Just worked with a mom who was giving her baby 24 oz formula a day (plus 8
breast sessions) and only at 6 weeks began to make a fuller supply.

Whether or not I find a reason for a low milk supply approach always the
same:  automatic double pump after each breast session.  At minimum try
fenugreek.  Ideally try Reglan.  Minimize stress.  Lots of calories.  Get
help for older sibling if possible.  If no response to all this then come up
with feeding approach that satisfies both parties.

Hope she responds.
Joanna Koch IBCLC in Los Altos, CA