Lives of the fellows

Ann Lindsay Stewart

b.13 July 1930 d.9 May 2004
MB ChB Bristol(1955) DCH(1958) MRCP(1994) FRCPCH(1997) FRCP(1999)

Ann Stewart was a senior lecturer in perinatal medicine and consultant paediatrician at University College Hospital, London. She ran the follow-up clinic for infants admitted to the neonatal intensive care unit there for nearly three decades and showed that the introduction of modern methods of care in the 1960s, such as mechanical ventilation and total parenteral nutrition, were associated with much improved chances of healthy survival for high risk infants, including very premature ones. However, a minority of the infants survived with neurodevelopmental disabilities, so from 1978 her main emphasis shifted to the investigation of the causes and prognostic significance of lesions in the brain detected by such objective techniques as ultrasound imaging and magnetic resonance spectroscopy. The results showed that perinatally acquired lesions were generally responsible for the disabilities.

Ann Stewart was born in Cornwall, where her father, William Lindsay Stewart, was a general practitioner. One of her first posts in Bristol after qualification was in paediatrics, where Beryl Corner and A V Neale [Munk's Roll, Vol.VI, p.355] encouraged her to make a career in the subject. During further posts in London she met and married her husband, Duncan Hutchison, a chest physician. They moved to Edinburgh where, as she put it, she became "a neonatologist before the specialty existed", with Jim Farquhar at the Elsie Inglis Memorial Maternity Hospital, where early feeding of premature babies was replacing the then customary strict regime of starvation. In 1965 Ann joined the MRC clinical and population research unit in Edinburgh, took part with Court Brown and Pat Jacobs in pioneering chromosome studies of newborn infants and first developed her lifelong enthusiasm for the follow up of vulnerable infants. After almost ten years in Edinburgh, she went to work with Harry Harris [Munk's Roll, Vol.X, p.199] at the Galton laboratory at UCL and soon after took on the UCH follow-up study.

In the 1960s the neonatal unit at UCH was in the forefront of developments in the newly emerging field of neonatal intensive care. This activity was regarded at the time with considerable suspicion, because Cecil Drillien in Edinburgh and others had shown that the prevalence of serious disability in surviving small premature infants born in the 1940s and 1950s was extremely high. It was generally thought that most had been irreversibly damaged before birth, so that attempts to help them live would merely result in the survival of increasing numbers of disabled children.

The view at UCH (and some other centres) was different - that these and other ill infants were prone to potentially brain-damaging insults such as hypoxaemia, hypoglycaemia, hyperbilirubinaemia and starvation, which were becoming progressively easier to detect and treat. Hence the introduction of a programme of care designed to prevent these and other adverse influences should improve the outcome. The only way to find out if this view had any substance was to keep all the survivors under surveillance. The follow-up study started at the beginning of 1966, with Ann in charge from 1968. A mass of obstetric and perinatal data was coded for each infant.

The initial question Ann addressed was to find out if most of the survivors progressing were normally. The first publication appeared in The Lancet in 1971. Fifty nine of the 72 inborn survivors weighing less than 1,500g admitted from 1966 to 1969 appeared to be progressing normally and only five were regarded as definitely abnormal. These findings created something of a storm and were widely disbelieved. However, Ann fought her corner with gusto, and Cecil Drillien sat in with her in the clinic and became convinced. Further follow up of these and many more children broadly confirmed the initial findings and showed that almost all were attending normal schools. Other groups enrolled included bigger premature infants, mechanically ventilated ones and those affected by severe rhesus haemolytic disease. Most of the survivors did well, so the question initially posed was answered in the affirmative.

But a minority of infants were affected by disabilities such as cerebral palsy and defects of hearing and vision. To investigate the causes, non-invasive methods of studying the neonatal brain were needed. Karen Pape, together with collaborators in the medical physics department, introduced cot-side ultrasound imaging in 1978. This enabled Ann to relate the appearance of the brain to long term outcome. Intraventricular haemorrage, although common in very premature infants, rarely led to disability unless severe. Hypoxic-ischaemic injury appeared more important, and was also the mechanism of brain injury in birth-asphyxiated term infants. Magnetic resonance spectroscopy was therefore used to explore cerebral energy metabolism in the first days of life. Again all the studied infants were followed up using structured neurodevelopmental assessments devised by Ann and her close friend Claudine Amiel-Tison. The exploration of these and other methods for examining the structure and function of the neonatal brain and relating the findings to outcome has greatly improved our understanding of the mechanisms of perinatal brain injury, and allowed preventive strategies to be tested and prognosis to be determined with reasonable precision.

Disability in the cohort could usually be ascribed to identifiable perinatal brain injury, but as the children reached four and eight years of age cognitive problems, usually minor, began to emerge. They were not related to detectable perinatal lesions. Ann therefore made collaborative arrangements with Robin Murray at the Institute of Psychiatry for the children (who now numbered 1,100 very premature infants and 600 others) to be kept under surveillance into adult life and the mechanisms of these problems investigated by functional MRI and other means. Exciting information has already been published.

Ann published 85 papers, chapters and reviews. She and Claudine Amiel-Tison edited an influential book entitled The newborn infant: one brain for life (Paris, Les Editions Inserm, c.1994). She gave many invited lectures and contributed to numerous advisory bodies at home and abroad, and she was an assistant editor of Early Human Development.

Ann had many interests outside medicine. She played lacrosse for Bristol University, and she was a keen walker and rider. She always dressed elegantly and was an avid collector of jewellery. She enjoyed all forms of art - perhaps not surprising as a great-granddaughter of the Scottish architect Alexander 'Greek' Thompson. She much enjoyed foreign travel.

She has transformed our understanding of the outcomes of neonatal intensive care and provided the means to think rationally about its difficult ethical dilemmas. She was loved by the children she tended and their parents, many of whom became lifelong friends. She influenced a generation of budding neonatologists.

Latterly, she developed debilitating Pick's disease and became progressively less able to communicate. Nevertheless, she continued to attend and contribute to meetings. She was looked after at home by her devoted family, her husband, Duncan, and their son and daughter, Peter and Celia.

Osmund Reynolds

(Volume XI, page 551)

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