Insufficient milk (real or perceived) is a major reason for formula supplementation and the abandonment of breastfeeding. Much of this issue can be attributed to mismanagement of early breastfeeding or a slow start due to multiple factors such as birth interventions, maternal diabetes and/or obesity, breast anomalies, and infants factors that preclude appropriate milk transfer. Interventions depend on the etiology of the cause and range from simply more breastfeeding all the way to milk expression and the use of galactagogues. There are however some situations where none of the traditional interventions work to resolve the problem. Is there something else going on in cases where our usual tricks don’t work? New research has identified two areas of concern–genetic and environmental. This presentation will go beyond the common etiology and interventions and look more deeply into genetic and environmental contributors to low milk supply.