**6.1. Growth**

normal as possible. Social and medical staff have to help the parents to overcome their own fears, and to allow patients to return to pre-illness activities within the restrictions of the illness

It is well established that children and adolescents with cancer experience malnutrition due to their underlying malignancy and treatment-related factors. Diminished nutritional status contributes in poor wound healing, increased infection risk, and decreased tolerance to chemotherapy. It is established that poor nutrition affects the QoL, response to treatment, and overall cost of care. This may be attributed to their limited energy stores and increased nutritional requirements to attain their appropriate growth and neurodevelopment [57–58].

Nutritional strategies should be integrated as a fundamental feature of supportive care for all pediatric neuro-oncology patients. The goals of nutritional supportive care include the maintenance of body stores, minimization of weight loss, promotion of appropriate growth,

Tumors of suprasellar and pineal region show various endocrine abnormalities even before the start of any treatment. Endocrinal symptoms in midline tumors include diabetes insipi‐ dus; changes in weight, height, and growth velocity; precocious puberty; or delayed sexual development. These symptoms less often lead to diagnosis, despite being present long before diagnosis [59]. Hypothalamic and pituitary endocrinopathies occur commonly in children following ≥24 Gy whole brain or localized cranial RT that included these structures in the radiation field. Hypothalamic-pituitary axis dysfunction gives rise to endocrinal abnormali‐ ties. This could be permanent or transient and the pituitary gland may regain its ability to secrete hormones after treatment. Therapeutic modalities, including surgery and radiothera‐ py, can damage pituitary cells leading to worsening of preexisting hypopituitarism [60]. Careful history and clinical examination, as well as timely reevaluation of children with abnormal body mass index (BMI) or BMI progression, as the presence of other neurological, ophthalmologic, and endocrine signs and symptoms may be indicative of the presence of an

The high cure rate achieved in pediatric CNS tumors is greatly attributable to refined neurosurgical procedures, the advancement in RT as well as chemotherapy and the multidis‐ ciplinary team decisions for treatment. However, with prolonged survival and on reaching adulthood, the incidence of late effects becomes more apparent. A majority of long-term survivors have at least one chronic medical sequelae [61]. These complications include endocrinopathy, osteoporosis, cerebrovascular disease, neurological and neurosensory

**5.3. Endocrinopathy at diagnosis and during treatment of brain tumor**

with no overindulging or overprotecting [54].

**5.2. Nutritional support**

464 Neurooncology - Newer Developments

and providing excellent QoL [58].

underlying hypothalamic-pituitary lesion [59, 60].

**6. Long-term sequelae**

Radiation-induced growth deficiency is due to damage to either hypothalamus or pituitary gland or local radiation to the spine. Cranial irradiation has an immediate suppressive effect on the hypothalamic-pituitary axis. According to the total cranial dose received, it reduces growth hormone (GH) level and alters the normal pubertal rise in GH secretions. The size and the number of radiation fractions influence growth hormone levels. Early diagnosis of mild hypothyroidism and/or GH deficiency permits early intervention to improve growth veloci‐ ty and QoL [62]. Craniospinal irradiation and/or disruption of the pituitary-hypothalamic axis can lead to more global changes in physical appearance such as short stature or obesity [62, 63].

Spinal radiation will affect vertebral body growth, especially in the younger ages. Chemo‐ therapy may impair gonadal function, usually more in males than in females. Cyclophospha‐ mide-induced testicular damage is dose dependent. In general, prepubertal patients tend to be more resistant to gonadal adverse effects of RT and chemotherapy than postpubertal patients [62].

#### **6.2. Osteoporosis**

Brain radiation, corticosteroids, poor nutrition, restricted weight-bearing exercise, and the developed endocrinopathies interact and all affect bone mineral density (BMD) during a crucial period for bone growth and skeletal growth. Depending on the magnitude of the BMD deficit and the potential for recovery, the pediatric neuro-oncology survivors are at in‐ creased risk for osteoporosis that may lead to osteoporotic fractures later in life.

These survivors should be assessed for low BMD and referred for potential bone health assessment and treatment as well as maximizing nutrition, exercise, and calcium and vita‐ min D intake [64].
