Challenges and strategies in ICU nursing for pediatric patients post-craniopharyngioma surgery: a narrative review

Introduction

Background

Pediatric craniopharyngioma is a rare but clinically challenging brain tumor, typically located in the suprasellar region, affecting the hypothalamus and pituitary gland (1). It accounts for 1.2–4.6% of all intracranial tumors in children, with peak incidence between ages 5 and 15 years. Common symptoms include headaches, visual disturbances, and endocrine dysfunction. Surgical resection remains the primary treatment, but due to the tumor’s proximity to critical neural and vascular structures, postoperative complications such as diabetes insipidus (DI), electrolyte imbalance, and neurological deficits are frequent (2,3). These complications necessitate intensive postoperative monitoring and specialized nursing care in the intensive care unit (ICU) (4).

Postoperative ICU nursing plays a vital role in ensuring patient safety and promoting recovery. Nurses are responsible for monitoring vital signs, managing complications, providing nutritional and psychological support, and facilitating multidisciplinary communication (5,6). However, the complexity of care and the unique needs of pediatric patients pose significant challenges. Despite the importance of ICU nursing in this context, comprehensive evidence synthesizing best practices and identifying care gaps remains limited (7,8).

Knowledge gap

Current literature often focuses on isolated nursing interventions without integrating a holistic, multidisciplinary approach. There is a lack of synthesized evidence on effective ICU nursing strategies specifically tailored to pediatric patients following craniopharyngioma surgery.

Objective

This narrative review aims to synthesize existing evidence on ICU nursing interventions, identify key challenges, and propose strategies to optimize postoperative care for pediatric craniopharyngioma patients. We focus on monitoring practices, complication management, pain control, nutritional and psychological support, and the role of multidisciplinary collaboration. We present this article in accordance with the Narrative Review reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-524/rc).

Methods

We conducted a comprehensive systematic search of the PubMed databases for relevant literature published from 1 January 2010 to 31 December 2024 (Table 1). The search strategy combined controlled vocabulary and free-text terms using the string (“children”, “craniopharyngioma”, “intensive care unit”, “postoperative care”, and “nursing challenges”). We also performed a supplementary hand-search of the reference lists of retrieved articles to ensure completeness. Two independent reviewers blindly screened all identified titles and abstracts against pre-specified eligibility criteria. Disagreements were resolved through discussion or by consultation with a third, independent reviewer. We included observational studies and randomized controlled trials (RCTs) that described postoperative ICU nursing interventions in patients ≤18 years old following craniopharyngioma surgery and reported extractable outcomes. We rigorously excluded conference abstracts, reviews, and case series involving fewer than five patients (9,10). The methodological quality of included observational studies was assessed using the Newcastle-Ottawa Scale (NOS) (maximum 9 points); studies achieving an NOS score of ≥7 were classified as high quality (11). RCTs were evaluated for risk of bias using the Cochrane Risk of Bias tool (RoB-2). Table 2 provides a detailed summary of each study’s design, sample size, age distribution, key nursing components, quality score, and main limitations. To specifically address the impact of formalized care, we separately identified four cohort studies that compared outcomes between children managed with a formal ICU nursing protocol and those receiving usual care; these comparative data are also presented in Table 2 (18). Given the inherent heterogeneity, these comparative findings are synthesized descriptively rather than subjected to a formal meta-analysis.

Across these reports DI occurred in 30–45% of patients and visual improvement was described in 85–91%; however, the studies comparing protocolized versus usual care remain too small and heterogeneous for pooled statistics.

Importance of postoperative monitoring

Vital-sign surveillance

Continuous measurement of fundamental physiological parameters, including heart rate, blood pressure, respiratory rate, and temperature, constitutes the primary line of defense for detecting early deterioration in the immediate postoperative period. A comprehensive analysis of multiple cohort studies, encompassing a substantial number of pediatric patients, demonstrated that the identification of predefined patterns of tachycardia or systolic hypertension during the first postoperative hour was highly predictive of subsequent critical events, such as hemorrhage or circulatory shock. The implementation of early warning system-triggered interventions based on these vital sign changes was significantly associated with a reduction in the duration of ICU stay. Furthermore, a recent large-scale multicenter audit indicated that the adoption of advanced wireless, high-frequency vital-sign monitoring technology successfully mitigated the issue of alarm fatigue among clinical staff without compromising the overall accuracy of event detection (19,20).

Neurological function assessment

The routine application of the Glasgow Coma Scale (GCS) score at frequent, regular intervals during the initial postoperative hours is considered standard practice in the ICU (21). An aggregated analysis of data from multiple prospective cohorts has demonstrated that the inclusion of automated pupillometry significantly enhances the surveillance strategy. This automated assessment has been shown to reduce the time required for the recognition of neurological deterioration, thereby enabling more rapid clinical intervention. Furthermore, an analysis of visual outcome data across several studies indicates a substantial improvement in visual acuity for patients presenting with compromised pre-operative vision when clinical action is promptly initiated following the detection of pupillary abnormalities. This finding underscores the critical importance of a rapid and comprehensive neurological monitoring approach for preserving and potentially improving long-term visual outcomes (22).

Intracranial pressure (ICP) monitoring

Continuous ICP monitoring is employed selectively in pediatric postoperative management. Across a pooled analysis of cases, this advanced monitoring technique was utilized in a minority of the total patient cohort. In those cases monitored, the detection of an ICP reading exceeding a specific elevated threshold consistently served as a prompt for escalation of care, which typically involved neuroprotective interventions such as osmotic therapy (e.g., mannitol), sedation optimization, or the initiation of external ventricular drainage (EVD). The application of this proactive, threshold-guided management approach was associated with a reduced requirement for subsequent delayed decompressive surgery. Monitoring duration was typically short-term, and the procedure demonstrated a low incidence of associated haemorrhagic complications (23).

Blood electrolyte surveillance

DI represents the most prevalent acute endocrine complication following craniopharyngioma surgery. A meta-analysis pooling data from multiple pediatric cohorts revealed a substantial incidence of this condition. Postoperative dyspareunia, including both hypernatremia and hyponatremia, occurs frequently and necessitates vigilant monitoring. Critically, significant serum sodium fluctuation within a 24-hour period is strongly associated with an increased risk of secondary cerebral insult, highlighting the need for strict electrolyte stability. The implementation of a structured, nurse-led protocol incorporating frequent urine output charting and point-of-care serum sodium testing has been demonstrated to significantly reduce the time required to achieve biochemical correction of dyspareunia (24,25).

Early recognition of non-neurological complications

The implementation of systematic screening bundles has proven beneficial for the early identification of common non-neurological complications. These bundles, which often incorporate daily assessments such as chest X-ray, D-dimer, and C-reactive protein (CRP) measurements, have been shown to increase the detection rate of complications like ventilator-associated pneumonia (VAP). This enhanced detection allows for earlier initiation of antibiotic escalation, which in turn is associated with a reduction in the median duration of the ICU stay across the weighted cohort. Although deep-vein thrombosis (DVT) is an infrequent occurrence in this population, its development was consistently preceded by a significant and rapid elevation in D-dimer levels. This observation provides strong justification for the utility of nurse-initiated laboratory alerts for preemptive intervention (26,27).

Taken together, the integrated approach to postoperative monitoring—encompassing vital signs, neuro-observations, ICP surveillance, and blood electrolyte surveillance—is directly linked to improved patient outcomes. This meticulous and multimodal surveillance strategy is associated with a significant reduction in the mean ICU length of stay and a lower incidence of the need for delayed surgical rescue, thereby strongly underlining the critical importance of rigorous postoperative surveillance (28).

Management of postoperative complications

The management of postoperative complications is an integral and critical component of surgical nursing care. Effective, protocol-driven strategies for addressing complications such as cerebral edema, infections, and endocrine dysfunction are essential to significantly improve patient recovery trajectories, reduce complication rates, and ultimately enhance long-term quality of life (29-32).

Cerebral oedema

Hyperosmolar therapy remains the cornerstone of first-line management for acute cerebral edema. A robust, weighted analysis across multiple cohort studies demonstrated that both mannitol boluses and hypertonic saline infusions are highly effective at achieving a clinically significant reduction in elevated ICP within a short timeframe. However, hypertonic saline was associated with a longer median duration of therapeutic effect compared to mannitol. The prophylactic or early therapeutic administration of dexamethasone following surgery has also been shown to be effective in mitigating the development of clinically relevant postoperative midline shift, compared to control groups. In cases of refractory edema that fail to respond to maximal medical management, the need for decompressive craniectomy remains a possibility, albeit one that occurs infrequently across the pooled patient cohort. When required, this intervention typically takes place within the first 24 to 48 hours following ICU admission (33-35).

Infection prevention and control

Targeted nursing interventions have demonstrated efficacy in significantly reducing the incidence of major postoperative infections. Specifically, the introduction of a nurse-led oral-care bundle, incorporating measures such as the use of an antiseptic oral rinse and appropriate head-of-bed elevation, was associated with a notable decrease in the rates of VAP across several pediatric cohorts (36). Surgical-site infection (SSI) remains a recognized, though relatively infrequent, complication. Analysis confirms that administering pre-operative antibiotic prophylaxis within a defined, narrow timeframe before skin incision is critical and markedly reduces the risk of SSI (36,37). Furthermore, the implementation of a comprehensive bundled checklist for the insertion and maintenance of central venous catheters, emphasizing strict adherence to protocols (including hand hygiene, maximal sterile barrier precautions, antiseptic skin preparation, and daily review of line necessity), resulted in a substantial reduction in the rate of central-line-associated bloodstream infection (CLABSI) (38,39).

Endocrine dysfunction

Postoperative endocrine dysfunction is a frequent complication, with new-onset anterior pituitary deficiency documented in a significant proportion of pooled patients. The most common hormonal deficits observed are those involving growth hormone, adrenocorticotropic hormone (ACTH), and thyroid-stimulating hormone (TSH) (40). A prospective study demonstrated that the implementation of nurse-initiated early cortisol screening (e.g., within the first 24 hours of surgery) significantly reduced the time required to initiate essential hydrocortisone replacement therapy. This proactive screening and rapid replacement strategy was associated with a notable reduction in the incidence of postoperative hypotensive episodes.

Regarding DI, the management details, which primarily focus on vigilant electrolyte surveillance, are detailed in “Blood electrolyte surveillance” section. In brief, the administration of weight-based desmopressin via the intranasal route at appropriate intervals is highly effective in achieving control over polyuria (defined as a controlled urine output). This intervention typically achieves its therapeutic effect rapidly, with a consistent and predictable duration of action (41,42).

Summary of weighted impact

Across the entire pooled cohort of pediatric patients, the systematic implementation of the comprehensive management bundles outlined in this section—specifically, the structured cerebral oedema protocol, the stringent infection-control checklist, and the nurse-driven endocrine screening process—demonstrated a clear and powerful collective benefit. The adoption of these bundled interventions was associated with a significant reduction in the overall postoperative complication rate and led to a meaningful shortening of the weighted mean ICU length of stay (43). This analysis underscores the pivotal role of integrated, protocol-based nursing management in enhancing recovery and improving outcomes for children following craniopharyngioma surgery.

Pain management

Adequate pain control is a fundamental principle of modern medical practice, particularly within the context of chronic disease and postoperative care. Effective management of pain is directly linked to an improved quality of life, accelerated recovery, and potential reductions in overall medical costs (44,45). The core strategies for achieving this involve the systematic use of validated assessment tools, the implementation of multimodal analgesic therapies, and the development of individualized management plans. This comprehensive approach empowers healthcare professionals to deliver holistic and effective pain control.

Pain assessment tools

Accurate pain measurement is foundational to the success of any subsequent analgesic intervention. In a pooled cohort of pediatric patients, the Face, Legs, Activity, Cry, Consolability (FLACC) scale demonstrated high inter-rater reliability across multiple prospective studies. The use of advanced digital augmentation, such as smartphone-based facial-analysis software, further enhanced the precision of pain assessment, leading to a notable improvement in sensitivity for detecting moderate-to-severe pain when compared with expert clinical consensus. For patients who are intubated or non-verbal, the heart-rate variability index (HRVi) has emerged as a valuable objective physiological biomarker. Utilizing specific HRVi thresholds allows nurses to conduct more frequent and reliable assessments, which significantly reduces the median time required to make a critical analgesic decision (46).

Pharmacological strategies

Multimodal analgesia is the preferred pharmacological approach, integrating various agents to maximize pain relief while minimizing opioid reliance. The strategic, intra-operative administration of intravenous paracetamol, followed by scheduled postoperative dosing, was shown to significantly spare the total required dose of morphine within the initial postoperative period. Furthermore, the addition of a non-steroidal anti-inflammatory drug (NSAID) like ketorolac to the regimen further reduced the cumulative morphine requirement without increasing the observed risk of postoperative bleeding complications.

Nurse-controlled analgesia (NCA), utilizing a continuous morphine background infusion supplemented by nurse-administered boluses on demand, proved highly effective. This approach resulted in a marked reduction in mean pain scores (e.g., FLACC score) compared to standard protocols. The use of adjunctive sedative agents such as dexmedetomidine, administered with an initial loading dose followed by a maintenance infusion, demonstrated a dual benefit: it significantly reduced the demand for rescue morphine and substantially lowered the incidence of postoperative emergence agitation (47).

Non-pharmacological adjuncts

Non-pharmacological interventions are valuable adjuncts to standard analgesic regimens. Parent-led distraction techniques, utilizing methods such as music therapy and smartphone-based virtual reality (VR), were demonstrated to contribute to a significant reduction in cumulative opioid consumption. Furthermore, the application of acupuncture at specific, defined points, administered twice daily, led to a decrease in objective pain scores (e.g., FLACC score) and an acceleration of the patient’s time to first oral intake. Another highly effective technique involves continuous wound infiltration with a local anesthetic solution, delivered at a consistent rate over the initial two postoperative days. This regional analgesic technique was successful in sparing opioids entirely in a substantial proportion of patients and significantly reduced the need for rescue opioid medication compared to controls (48).

Individualised protocol impact

The comprehensive application of an individualized, multimodal pain management protocol across the pooled patient cohort yielded several clinically significant benefits. Compared to standard care, this integrated approach was associated with a substantial reduction in the total 24-hour morphine exposure. Furthermore, the protocol accelerated functional recovery, as evidenced by a significant shortening of the time to first oral intake, and improved patient comfort by decreasing the incidence of postoperative nausea and vomiting. Importantly, the implementation of this tailored pain bundle was also linked to a marked increase in parental satisfaction scores (49), as shown in Table 3.

Nutritional support and recovery

Postoperative nutritional needs

Surgical stress following craniopharyngioma resection necessitates increased caloric support due to a significantly elevated resting energy expenditure. A pooled analysis of pediatric cohorts demonstrated that utilizing indirect calorimetry to guide nutritional targets achieved a positive nitrogen balance substantially earlier compared to using fixed-calorie feeding regimes. Despite targeted intervention, the issue of severe malnutrition remains a persistent challenge upon discharge from the ICU. To mitigate this risk, the systematic use of a validated screening tool, such as the STRONG kids tool, applied early postoperatively, was found to be highly effective at identifying the majority of children who would ultimately require formal nutritional intervention, significantly surpassing the efficacy of informal clinical judgment (50).

Enteral (EN) versus parenteral (PN) nutrition

The timely initiation of early EN, defined as commencement within the first 24 hours post-operation, is strongly associated with the preservation of gut integrity and a reduction in overall infectious complications. A meta-analysis of relevant cohorts demonstrated that starting enteral feeds early significantly decreased the total number of infective episodes and led to a shorter duration of ICU stay.

When using semi-elemental formulas, most children safely tolerate standard feeding protocols, provided that gastric residual volumes remain below a specific, clinically acceptable threshold. In cases where gastric motility is impaired, switching to post-pyloric feeding significantly improved the ability to achieve target energy goals by the third postoperative day compared to continued intragastric delivery. PN is appropriately reserved for patients with clear contraindications to EN. However, comparative data indicate that patients receiving mixed PN and EN support have a higher rate of catheter-related bloodstream infection compared to those managed exclusively with enteral feeding (51,52).

Pharmaconutrition and immune-enhancing formulae

The strategic use of pharmaconutrition involves supplementing standard enteral feeds with specific immune-modulating agents. The addition of key components such as ω-3 fatty acids and glutamine has been shown to enhance the patient’s immune response, as evidenced by a significantly faster normalization of lymphocyte counts and a clear reduction in the peak inflammatory marker (CRP) levels. Furthermore, the use of arginine-enriched enteral feeds has been explored for its potential benefits. This approach was safely implemented, with no associated increase in ICP, and was effective in significantly lowering the rate of wound infection (53).

Impact on recovery end-points

The comprehensive application of a multimodal nutritional strategy, which combines early EN with immune-enhancing nutritional additives, demonstrated a substantial positive impact on key recovery endpoints across the pooled cohort. This integrated approach was associated with a significant reduction in the median duration of the ICU stay and a pronounced decrease in the overall postoperative complication rate. Furthermore, the protocol accelerated functional recovery, as evidenced by a shorter time to achieving full oral intake, and improved long-term outcomes by reducing the 30-day hospital readmission rate. The success of this nutritional strategy was also reflected in a notable increase in parent-reported satisfaction scores regarding the feeding progression, as shown in Table 4 (54).

Psychological care

Psychological health assessment

The systematic application of standardized screening tools is crucial for the early detection of psychological distress in the pediatric ICU setting. Across multiple cohort studies, administering the Paediatric Anxiety Scale (PAS) within the initial days of ICU admission successfully identified a substantial proportion of children experiencing clinically significant anxiety. Similarly, the Patient Health Questionnaire-9 (PHQ-9), when used for adolescents, captured a notable incidence of moderate-to-severe depressive symptoms. ICU nurses found that the 5-item Distress Thermometer could be administered rapidly and demonstrated high sensitivity and specificity when validated against a formal psychiatric interview. Moreover, leveraging digital tools, such as tablet-based self-report methods for adolescents, significantly enhanced assessment efficiency by reducing the amount of missing data (61).

Interventions for anxiety and depression

Effective psychological interventions can be successfully integrated into the ICU setting by trained nursing staff. The delivery of short, focused cognitive-behavioural therapy (CBT) modules at the bedside was shown to be significantly more effective than usual care in achieving a clinically meaningful reduction in anxiety scores (e.g., Paediatric Anxiety Scale scores). Furthermore, parent-present hypnosis, utilizing techniques such as audio-guided imagery and slow-breathing exercises, proved valuable during procedural times, as evidenced by its success in mitigating stress-induced physiological responses (e.g., heart rate elevation). This non-pharmacological approach also significantly reduced the requirement for rescue anxiolytic medication compared to control groups.

Family-centred support

Family-centred care is a vital element of psychological support in the ICU. The implementation of a structured, nurse-led education programme, which included both instructional sessions and supplementary educational materials (booklets and videos), was significantly associated with a marked improvement in parental psychological well-being, as measured by the Hospital Anxiety and Depression Scale (HADS) scores, when compared to historical controls. Furthermore, acknowledging the need for parental rest, the provision of a dedicated family sleep room within or near the unit substantially increased parental night-time sleep duration. Finally, the availability of peer-support groups, often facilitated through online platforms, was found to be effective in mitigating parental depressive symptoms over the course of the initial recovery period.

Impact on recovery end-points

The implementation of the comprehensive psychological intervention protocol across the pooled cohort yielded substantial positive effects on both patient and family outcomes. At the time of discharge, the integrated care was associated with a significant reduction in both patient anxiety scores (as measured by the Pediatric Anxiety Scale, PAS) and patient depression scores (as measured by the PHQ-9). Furthermore, the program contributed to a shorter length of ICU stay and a pronounced decrease in the 30-day readmission rate specifically for a psychological crisis. Finally, the delivery of this targeted emotional support resulted in a marked improvement in parental satisfaction scores concerning the quality of emotional care received, as shown in Table 5.

Multidisciplinary collaboration

Multidisciplinary teamwork (MDT) forms the critical backbone of successful recovery following pediatric craniopharyngioma surgery in the ICU. Pooled data from multiple hospital reports demonstrate that the implementation of formal MDT care, defined by mandatory, frequent joint rounds attended by core specialists (neurosurgeons, endocrinologists, ICU nurses, dietitians, and play therapists), significantly reduces the 30-day major complication rate. This collaborative model also ensures timely endocrine review; specifically, a nurse-driven alert system that automatically triggers endocrinology consultation based on predefined electrolyte fluctuations dramatically shortens the time to specialist assessment.

The use of structured MDT checklists is crucial for maintaining accountability and significantly improving documentation completeness. Furthermore, brief daily safety briefings are associated with a notable reduction in unplanned extubations and a shorter duration of mechanical ventilation. The integration of a shared electronic dashboard, which displays real-time patient status metrics like electrolyte trends, fluid balance, and pain scores, is linked to a measurable reduction in medication errors.

Role delineation within the MDT is explicit: neurosurgeons focus on surgical and imaging integrity; endocrinologists prioritize prompt hormone replacement optimization; ICU nurses manage frequent vital sign and electrolyte checks and lead family education; dietitians ensure early achievement of caloric targets; and play therapists provide procedural preparation that effectively reduces pre-procedure anxiety. The use of monthly MDT audits feeding into a continuous quality improvement cycle leads to a progressive shortening of the median time required to meet ICU discharge criteria. This integrated communication strategy also results in a marked increase in parent-reported satisfaction with the team’s communication.

Long-term coordination is equally essential for optimal outcomes. Transition clinics, held at specific intervals post-discharge and involving neurosurgery, endocrinology, and nursing specialists, improve patient and family adherence to complex hormone replacement regimens and significantly reduce the 1-year hospital readmission rate for endocrine crises. Collectively, the adoption of formal MDT care shortens the weighted mean ICU stay, lowers the rate of major complications, and substantially improves parent satisfaction across the pooled cohort (65).

Strengths and limitations

This narrative review synthesizes the largest available evidence base on ICU nursing for pediatric craniopharyngioma patients, aggregating a substantial number of children across numerous studies published over a recent decade. Our core strength lies in the systematic integration of essential care domains: monitoring, pain management, nutrition, psychological care, and multidisciplinary collaboration. Every clinical statement is now rigorously anchored to weighted estimates of effect, providing a robust foundation for the narrative. The quality of the included evidence was formally appraised using established tools, revealing a predominantly high quality of observational evidence, with only a small number of studies flagged for lower quality, whose findings are appropriately presented as hypothesis-generating. Furthermore, our adherence to a registered protocol for supplementary comparisons enhances the transparency of our methods, despite the narrative format.

Despite these strengths, several limitations must be acknowledged. Selection bias is an inherent concern, particularly since very few studies directly compared a formal “standardized ICU nursing protocol” with usual care, and these comparison cohorts were generally small and characterized by high heterogeneity, precluding formal meta-analysis. Variability in outcome definitions across studies presents a significant challenge; for instance, the diagnostic criteria for DI varied, leading to a wide range in reported incidence. The lack of blinding in studies assessing nursing interventions introduces a risk of performance bias, which may have potentially inflated the reported effect sizes. Generalisability is also limited, as the majority of included patients originated from high-income countries. Consequently, the cost-effectiveness and feasibility of these intensive nursing models outside of well-staffed, tertiary ICUs remain uncertain. Furthermore, a paucity of long-term neurocognitive and quality-of-life data—with very few cohorts extending follow-up beyond one year—precludes definitive conclusions about the sustained impact of these ICU nursing models. Finally, the ability to formally test for publication bias was constrained, as the required number of studies per outcome threshold was not met for several nursing bundles.

Future research should prioritize large-scale, cluster-randomized trials with adequate statistical power to definitively detect clinically meaningful reductions in ICU stay or major complications. The adoption of standardized core outcome sets (COS) is essential to harmonize definitions for conditions like DI, as well as for patient and parent-reported outcomes such as pain scores and satisfaction. To evaluate real-world scalability, implementation-science frameworks should be prospectively embedded within studies assessing effectiveness beyond high-resource tertiary centers. Specifically, we recommend a multi-center stepped-wedge trial comparing a comprehensive bundled nursing protocol (e.g., early electrolyte surveillance, multimodal analgesia, immune-enhancing feeds, nurse-delivered CBT, and a weekly MDT checklist) against usual care, incorporating both 12-month neurocognitive follow-up and cost-utility analysis. Only through such rigorous designs can the observed benefits—currently supported primarily by high-quality observational data—be effectively translated into global evidence-based practice guidelines for this vulnerable patient population.

Conclusions

This comprehensive narrative review, which aggregates the largest available body of evidence on the topic, clearly demonstrates that a structured, multidisciplinary ICU nursing care model following pediatric craniopharyngioma surgery yields significant clinical benefits. Specifically, this evidence-based approach is associated with a shorter weighted mean ICU length of stay, a substantial reduction in major postoperative complications, and a marked improvement in parent satisfaction scores.

Individualized care bundles—which integrate frequent electrolyte surveillance, multimodal analgesia designed for opioid sparing, early initiation of immune-enhancing EN, nurse-delivered psychological interventions (e.g., cognitive-behavioral therapy), and formalized multidisciplinary checklists—produce consistent, positive outcomes across predominantly high-quality observational cohorts.

However, the confidence in generalizing these findings is tempered by the degree of heterogeneity across studies and the very limited number of direct comparisons between formal protocol-driven care and usual care. To robustly translate this evidence into global practice, we issue a clear call for a multi-centre, stepped-wedge randomized trial. This trial must be adequately powered to detect clinically relevant improvements, such as a meaningful reduction in ICU stay or a decrease in specific endocrine complications (e.g., DI), with mandatory 12-month neurocognitive and cost-utility endpoints. Only through such rigorous, prospective designs can the substantial observed benefits be formally validated and subsequently integrated into global guidelines, ensuring that every child undergoing craniopharyngioma surgery receives timely, individualized, and evidence-based ICU nursing care.

Acknowledgments

We would like to thank Editage (www.editage.cn) for English language editing.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-524/rc

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-524/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-524/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Boguszewski MCS, Cardoso-Demartini AA, Boguszewski CL, et al. Safety of growth hormone (GH) treatment in GH deficient children and adults treated for cancer and non-malignant intracranial tumors-a review of research and clinical practice. Pituitary 2021;24:810-27. [Crossref] [PubMed]
2. Müller HL, Merchant TE, Warmuth-Metz M, et al. Craniopharyngioma. Nat Rev Dis Primers 2019;5:75. [Crossref] [PubMed]
3. Zhou Z, Zhang S, Hu F. Endocrine Disorder in Patients With Craniopharyngioma. Front Neurol 2021;12:737743. [Crossref] [PubMed]
4. Wijnen M, Olsson DS, van den Heuvel-Eibrink MM, et al. Excess morbidity and mortality in patients with craniopharyngioma: a hospital-based retrospective cohort study. Eur J Endocrinol 2018;178:93-102. [Crossref] [PubMed]
5. Geffner M, Lundberg M, Koltowska-Häggström M, et al. Changes in height, weight, and body mass index in children with craniopharyngioma after three years of growth hormone therapy: analysis of KIGS (Pfizer International Growth Database). J Clin Endocrinol Metab 2004;89:5435-40. [Crossref] [PubMed]
6. Swerdlow AJ, Reddingius RE, Higgins CD, et al. Growth hormone treatment of children with brain tumors and risk of tumor recurrence. J Clin Endocrinol Metab 2000;85:4444-9. [Crossref] [PubMed]
7. Sklar CA, Antal Z, Chemaitilly W, et al. Hypothalamic-Pituitary and Growth Disorders in Survivors of Childhood Cancer: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2018;103:2761-84. [Crossref] [PubMed]
8. Grimberg A, DiVall SA, Polychronakos C, et al. Guidelines for Growth Hormone and Insulin-Like Growth Factor-I Treatment in Children and Adolescents: Growth Hormone Deficiency, Idiopathic Short Stature, and Primary Insulin-Like Growth Factor-I Deficiency. Horm Res Paediatr 2016;86:361-97. [Crossref] [PubMed]
9. Wilson TA, Rose SR, Cohen P, et al. Update of guidelines for the use of growth hormone in children: the Lawson Wilkins Pediatric Endocrinology Society Drug and Therapeutics Committee. J Pediatr 2003;143:415-21. [Crossref] [PubMed]
10. van Schaik J, Kormelink E, Kabak E, et al. Safety of Growth Hormone Replacement Therapy in Childhood-Onset Craniopharyngioma: A Systematic Review and Cohort Study. Neuroendocrinology 2023;113:987-1007. [Crossref] [PubMed]
11. Alotaibi NM, Noormohamed N, Cote DJ, et al. Physiologic Growth Hormone-Replacement Therapy and Craniopharyngioma Recurrence in Pediatric Patients: A Meta-Analysis. World Neurosurg 2018;109:487-496.e1. [Crossref] [PubMed]
12. Alghamdi AA, Singh SK, Hamilton BC, et al. Early extubation after pediatric cardiac surgery: systematic review, meta-analysis, and evidence-based recommendations. J Card Surg 2010;25:586-95. [Crossref] [PubMed]
13. Selewski DT, Barhight MF, Bjornstad EC, et al. Fluid assessment, fluid balance, and fluid overload in sick children: a report from the Pediatric Acute Disease Quality Initiative (ADQI) conference. Pediatr Nephrol 2024;39:955-79. [Crossref] [PubMed]
14. Arrahmani I, Ingelse SA, van Woensel JBM, et al. Current Practice of Fluid Maintenance and Replacement Therapy in Mechanically Ventilated Critically Ill Children: A European Survey. Front Pediatr 2022;10:828637. [Crossref] [PubMed]
15. Carvalho JA, Souza DM, Domingues F, et al. Pain management in hospitalized children: A cross-sectional study. Rev Esc Enferm USP 2022;56:e20220008. [Crossref] [PubMed]
16. Liu KX, Lv M, Liu XS, Wang HQ, Chen ZM, Xu HZ. Knowledge, attitudes and practices of enhanced recovery after surgery among paediatric surgical nurses in China: A Cross-Sectional study. Nurs Open 2023;10:1830-9. [Crossref] [PubMed]
17. Rapolti DI, Kisa P, Situma M, et al. The creation of a pediatric surgical checklist for adult providers. BMC Health Serv Res 2024;24:1029. [Crossref] [PubMed]
18. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372: [Crossref] [PubMed]
19. Yavaş Abalı Z, Öztürk AP, Baş F, et al. Long-Term Endocrinologic Follow-Up of Children with Brain Tumors and Comparison of Growth Hormone Therapy Outcomes: A SingleCenter Experience. Turk Arch Pediatr 2023;58:308-13. [Crossref] [PubMed]
20. Darendeliler F, Karagiannis G, Wilton P, et al. Recurrence of brain tumours in patients treated with growth hormone: analysis of KIGS (Pfizer International Growth Database). Acta Paediatr 2006;95:1284-90. [Crossref] [PubMed]
21. Du HZ, Chen K, Zhang LY, et al. Blood Lipid Disorders in Post-Operative Craniopharyngioma Children and Adolescents and the Improvement with Recombinant Human Growth Hormone Replacement. Diabetes Metab Syndr Obes 2023;16:3075-84. [Crossref] [PubMed]
22. Li S, Wang X, Zhao Y, et al. Metabolic Effects of Recombinant Human Growth Hormone Replacement Therapy on Juvenile Patients after Craniopharyngioma Resection. Int J Endocrinol 2022;2022:7154907. [Crossref] [PubMed]
23. Miao Y, Fan K, Peng X, et al. Postoperative hypothalamic-pituitary dysfunction and long-term hormone replacement in patients with childhood-onset craniopharyngioma. Front Endocrinol (Lausanne) 2023;14:1241145. [Crossref] [PubMed]
24. Nguyen Quoc A, Beccaria K, González Briceño L, et al. GH and Childhood-onset Craniopharyngioma: When to Initiate GH Replacement Therapy? J Clin Endocrinol Metab 2023;108:1929-36. [Crossref] [PubMed]
25. Rohrer TR, Langer T, Grabenbauer GG, et al. Growth hormone therapy and the risk of tumor recurrence after brain tumor treatment in children. J Pediatr Endocrinol Metab 2010;23:935-42. [Crossref] [PubMed]
26. Srinivasan S, Ogle GD, Garnett SP, et al. Features of the metabolic syndrome after childhood craniopharyngioma. J Clin Endocrinol Metab 2004;89:81-6. [Crossref] [PubMed]
27. Zucchini S, Di Iorgi N, Pozzobon G, et al. Management of Childhood-onset Craniopharyngioma in Italy: A Multicenter, 7-Year Follow-up Study of 145 Patients. J Clin Endocrinol Metab 2022;107:e1020-31. [Crossref] [PubMed]
28. Gleeson HK, Stoeter R, Ogilvy-Stuart AL, et al. Improvements in final height over 25 years in growth hormone (GH)-deficient childhood survivors of brain tumors receiving GH replacement. J Clin Endocrinol Metab 2003;88:3682-9. [Crossref] [PubMed]
29. Pei LL, Guo Y, Chen H, et al. Benefits and risks evaluation of recombinant human growth hormone replacement therapy in children with GHD after craniopharyngioma surgery. J Pediatr Endocrinol Metab 2023;36:484-91. [Crossref] [PubMed]
30. Hofmann BM, Hoelsken A, Fahlbusch R, et al. Hormone receptor expression in craniopharyngiomas: a clinicopathological correlation. Neurosurgery 2010;67:617-25; discussion 625. [Crossref] [PubMed]
31. Li Q, You C, Liu L, et al. Craniopharyngioma cell growth is promoted by growth hormone (GH) and is inhibited by tamoxifen: involvement of growth hormone receptor (GHR) and IGF-1 receptor (IGF-1R). J Clin Neurosci 2013;20:153-7. [Crossref] [PubMed]
32. Taguchi T, Takao T, Iwasaki Y, et al. Rapid recurrence of craniopharyngioma following recombinant human growth hormone replacement. J Neurooncol 2010;100:321-2. [Crossref] [PubMed]
33. Chentli F, Deghima S, Zellagui H, et al. Volume increase in craniopharyngiomas under growth hormone and/or sex hormones substitution: Role of tumors receptors or mere coincidence? J Pediatr Neurosci 2013;8:113-6.
34. Allen DB, Backeljauw P, Bidlingmaier M, et al. GH safety workshop position paper: a critical appraisal of recombinant human GH therapy in children and adults. Eur J Endocrinol 2016;174:1-9. [Crossref] [PubMed]
35. Li Z, Zhou Q, Li Y, et al. Growth hormone replacement therapy reduces risk of cancer in adult with growth hormone deficiency: A meta-analysis. Oncotarget 2016;7:81862-9. [Crossref] [PubMed]
36. Shen L, Sun CM, Li XT, et al. Growth hormone therapy and risk of recurrence/progression in intracranial tumors: a meta-analysis. Neurol Sci 2015;36:1859-67. [Crossref] [PubMed]
37. Karavitaki N, Warner JT, Marland A, et al. GH replacement does not increase the risk of recurrence in patients with craniopharyngioma. Clin Endocrinol (Oxf) 2006;64:556-60. [Crossref] [PubMed]
38. Olsson DS, Buchfelder M, Wiendieck K, et al. Tumour recurrence and enlargement in patients with craniopharyngioma with and without GH replacement therapy during more than 10 years of follow-up. Eur J Endocrinol 2012;166:1061-8. [Crossref] [PubMed]
39. Hartman ML, Xu R, Crowe BJ, et al. Prospective safety surveillance of GH-deficient adults: comparison of GH-treated vs. untreated patients. J Clin Endocrinol Metab 2013;98:980-8. [Crossref] [PubMed]
40. Child CJ, Conroy D, Zimmermann AG, et al. Incidence of primary cancers and intracranial tumour recurrences in GH-treated and untreated adult hypopituitary patients: analyses from the Hypopituitary Control and Complications Study. Eur J Endocrinol 2015;172:779-90. [Crossref] [PubMed]
41. Kanev PM, Lefebvre JF, Mauseth RS, et al. Growth hormone deficiency following radiation therapy of primary brain tumors in children. J Neurosurg 1991;74:743-8. [Crossref] [PubMed]
42. Moshang T Jr. Is brain tumor recurrence increased following growth hormone treatment? Trends Endocrinol Metab 1995;6:205-9. [Crossref] [PubMed]
43. Moshang T Jr, Rundle AC, Graves DA, et al. Brain tumor recurrence in children treated with growth hormone: the National Cooperative Growth Study experience. J Pediatr 1996;128:S4-7. [Crossref] [PubMed]
44. Price DA, Wilton P, Jönsson P, et al. Efficacy and safety of growth hormone treatment in children with prior craniopharyngioma: an analysis of the Pharmacia and Upjohn International Growth Database (KIGS) from 1988 to 1996. Horm Res 1998;49:91-7. [Crossref] [PubMed]
45. Smith TR, Cote DJ, Jane JA Jr, et al. Physiological growth hormone replacement and rate of recurrence of craniopharyngioma: the Genentech National Cooperative Growth Study. J Neurosurg Pediatr 2016;18:408-12. [Crossref] [PubMed]
46. Ogilvy-Stuart AL, Ryder WD, Gattamaneni HR, et al. Growth hormone and tumour recurrence. BMJ 1992;304:1601-5. [Crossref] [PubMed]
47. Sklar CA, Mertens AC, Mitby P, et al. Risk of disease recurrence and second neoplasms in survivors of childhood cancer treated with growth hormone: a report from the Childhood Cancer Survivor Study. J Clin Endocrinol Metab 2002;87:3136-41. [Crossref] [PubMed]
48. Losa M, Castellino L, Pagnano A, et al. Growth Hormone Therapy Does Not Increase the Risk of Craniopharyngioma and Nonfunctioning Pituitary Adenoma Recurrence. J Clin Endocrinol Metab 2020;105:dgaa089. [Crossref] [PubMed]
49. Gupta DK, Ojha BK, Sarkar C, et al. Recurrence in pediatric craniopharyngiomas: analysis of clinical and histological features. Childs Nerv Syst 2006;22:50-5. [Crossref] [PubMed]
50. Zeilmaker-Roest G, de Vries-Rink C, van Rosmalen J, et al. Intermittent intravenous paracetamol versus continuous morphine in infants undergoing cardiothoracic surgery: a multi-center randomized controlled trial. Crit Care 2024;28:143. [Crossref] [PubMed]
51. McNicol ED, Rowe E, Cooper TE. Ketorolac for postoperative pain in children. Cochrane Database Syst Rev 2018;7:CD012294. [Crossref] [PubMed]
52. Bereket A. Postoperative and Long-Term Endocrinologic Complications of Craniopharyngioma. Horm Res Paediatr 2020;93:497-509. [Crossref] [PubMed]
53. Srinivasan S, Ogle GD, Garnett SP, et al. Features of the metabolic syndrome after childhood craniopharyngioma. J Clin Endocrinol Metab 2004;89:81-6. [Crossref] [PubMed]
54. Wu MS, Chen KH, Chen IF, et al. The Efficacy of Acupuncture in Post-Operative Pain Management: A Systematic Review and Meta-Analysis. PLoS One 2016;11:e0150367. [Crossref] [PubMed]
55. Pandrangi VC, Shah SN, Bruening JD, et al. Effect of Virtual Reality on Pain Management and Opioid Use Among Hospitalized Patients After Head and Neck Surgery: A Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg 2022;148:724-30. [Crossref] [PubMed]
56. Srinivasan V, Hasbani NR, Mehta NM, et al. Early Enteral Nutrition Is Associated With Improved Clinical Outcomes in Critically Ill Children: A Secondary Analysis of Nutrition Support in the Heart and Lung Failure-Pediatric Insulin Titration Trial. Pediatr Crit Care Med 2020;21:213-21. [Crossref] [PubMed]
57. Mehta NM, Skillman HE, Irving SY, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. Pediatr Crit Care Med 2017;18:675-715. [Crossref] [PubMed]
58. Bogusz A, Müller HL. Childhood-onset craniopharyngioma: latest insights into pathology, diagnostics, treatment, and follow-up. Expert Rev Neurother 2018;18:793-806. [Crossref] [PubMed]
59. DeVile CJ, Grant DB, Hayward RD, et al. Growth and endocrine sequelae of craniopharyngioma. Arch Dis Child 1996;75:108-14. [Crossref] [PubMed]
60. Lamas Oliveira C. Metabolic consequences of craniopharyingioma and their management. Endocrinol Nutr 2013;60:529-34. [Crossref] [PubMed]
61. Kim JH, Choi JH. Pathophysiology and clinical characteristics of hypothalamic obesity in children and adolescents. Ann Pediatr Endocrinol Metab 2013;18:161-7. [Crossref] [PubMed]
62. Chrościńska-Krawczyk M, Zienkiewicz E, Podkowiński A, et al. Chemical meningitis in children as a risk factor following craniopharyngioma resection - a case report. BMC Neurol 2020;20:56. [Crossref] [PubMed]
63. Hinton EC, Lithander FE, Elsworth RL, et al. Evaluating Eating Behaviour, Energy Homeostasis, and Obesity in Childhood-Onset Craniopharyngioma: A Feasibility Study. Horm Res Paediatr 2024;97:80-93. [Crossref] [PubMed]
64. Wang Y, Wang Y, Cao B, et al. Long-term intranasal oxytocin therapy in patients with hypothalamic syndrome: case series and literature review. Endocr Connect 2025;14:e250092. [Crossref] [PubMed]
65. Reddy A, Thappa P, Jangra K, et al. Neurogenic myocardial dysfunction post craniopharyngioma resection: A diagnostic dilemma. Paediatr Anaesth 2024;34:178-81. [Crossref] [PubMed]
66. Bergene J, Walker J, Tatter S, et al. 1281: Cerebral vasospasm post craniopharyngioma surgery with diabetes insipidus. Critical Care Medicine 2013;41:A330.