But back to the issue at hand the mother with a low supply....

I educate the mothers about the importance of first getting themselves  
into the permissive state.
If they are not already nursing or pumping 10 times a day I ask them  
to do it.
I explain that after 3 hours without nipple stimulation their milk  
making hormone levels decline
and if four hours go by without a nursing /breast emptying their brain  
will
make two hormones that work against milk production.

I explain that frequency is more important than duration.
I explain that we have got to get them into a permissive hormonal  
state before they can
expect to see any increase in milk volume.
If they are pump dependent I ask them to double pump just 15-20  
minutes until the milk appears,
  or if there is already some milk I ask them to pump just 20 minutes  
10 times a day for the first 24 hours.

If a mother complains to me about the frequency I do the math for her.
Usually mothers have it in their heads that 8 times a day should be  
enough,
  and they are willing to pump for or nurse for 30 minutes but just 8  
times day.
I point out to them that 30 minutes 8 times a day is 240 minutes a day
and I am only asking them to pump 20 minutes 10 times a day which is  
just 200 minutes-
40 minutes less a day then they are now pumping.

Once I have got them nursing or pumping ten times a day I explain that  
now that they are in the
permissive state nursing pumping longer will increase the volume of  
milk they are making.
Once they see their bodies responding to the better frequency they  
really don't have to be
cajoled into pumping or nursing longer...pumping becomes its own reward.

I also explain if they nurse/pump frequently during the day (every two  
hours or less) but
take a long stretch of sleep at night of 4-6 hours they will be  
undoing a lot of the work
they had been putting into build their supply the previous day. I  
explain that feeling of
fullness, when they go too long between breast emptyings, is deceptive  
because it
represents the milk production stimulated by the frequent stimulations  
they got earlier in
the day, but in the day following a long stretch of sleep, the  
hormones produced during
that long stretch of sleep will exert their effect and they will see  
their milk production go
down.

I tell the mom 10-12 breast emptyings a day is what I recommend while  
she is building
her supply and once her supply is in fully she may be able to fall  
back to just nine
nursings/pumpings a day but I caution her that falling back to just 8  
nursings a day places
her precariously close to falling off that cliff again where she finds  
her milk production
down regulating.

I tell her that once she has a full milk supply she and her baby may  
be able to take one
long stretch of sleep of 4-6 hours in a 24 hour period and still have  
a great milk supply
and a baby growing like a weed IF the other nursings of the day are  
under 2.5 hours
apart but they may need to be as close as 1.5 hours apart. (Pick your  
poison- long stretch
of sleep with possibly super frequent day nursings or less frequent  
daytime nursings but
no reduce frequency of nursing at night.)

If the mother is emptying her breast frequently and effectively enough  
but she is still not
making enough milk you have to ask herself what could be going on with  
her hormonally
that is preventing her from entering the permissive state.

Does she have a retained placental fragment,
is she a diabetic or insulin resistant, does she have low thyroid,
does she have an ovarian cyst,
is she retaining fluid,
is she taking medications which alter brain chemistry, etc
and of course has some fool given her contraceptives?

If nothing sees to be amiss having to do with adequate removal and the  
permissive state
you have to wonder about glandular tissue and ask questions about what  
happened at the
birth like postpartum hemorrhage, breast development during pregnancy,  
and take into
consideration appearance.

You don't want to alarm the mother about appearance until you have  
tried good
management and galactogogues because the proof is always in the  
pudding, but is also
cruel to let a mother with tubular breasts or no mounding whatsoever  
beat her head
against a wall too long.

And of course there are the things don't seem to fall under any the  
heading- not the
permissive state, not inadequate milk removal, not insufficient  
glandular...gastric by pass
or other extreme conditions which induce malnutrition in the mother.  
In these really
unusual cases sometimes I see the extremes of no milk at all, or  
normal volumes but
slow gaining baby anyway, which is my first heads up that the normal  
interventions are
not going to work.

Whew,
Jen O'Quinn IBCLC

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