BACKGROUND: The authors present their current attitude towards management of craniopharyngiomas in children. Radical surgery cannot be performed when one is not sure about its potential danger to the visual pathways and the hypothalamus. METHODS: Most of the surgeries that have been performed in our institution via an intracranial approach were incomplete and followed by radiotherapy, in the last 10 years with stereotactic conformational radiotherapy. DISCUSSION: Considering our past and present experience concerning the transphenoidal approach for treatment of craniopharyngiomas, we make a plea for the consideration of this approach in children whenever feasible (around 25% of the cases in children older than 5 years). Craniopharyngiomas that can be removed by this approach represent a milder form of the disease and the results concerning the visual, hypothalamic functions and quality of life are significantly better than that obtained via an intracranial approach. When the craniopharyngioma cannot be removed by this approach because of tight hypothalamic adherences, the technique of cystosphenoidostomy with a custom-made shunt plus adjuvant stereotactic conformational radiotherapy is an alternative for its total removal.