Idiopathic thrombocytopenic purpura (ITP) is an often, but not always, self-limited bleeding disorder of childhood of unknown etiology. Duration of more than 6 months defines the chronic form and this occurs in approximately 20% of children and is the common form of the disorder in adults. At initial diagnosis, neither the individual bleeding risk nor the form of the disease, acute or chronic, is predictable, which exposes doctors and parents to fear of life-threatening bleeding. Consequently a majority of children will receive platelet-enhancing therapy to prevent major bleeding manifestations. Prophylactic interventions have proven to be effective in raising the platelet count within a short time period in several prospective trials, however two questions may be raised, (1) whether a rapid platelet increase efficiently prevents serious bleeding and (2) whether such a prophylactic intervention is of clinical value. Furthermore, a small subgroup of patients with major bleeding manifestations seems to be treated inadequately, since patients of this subgroup may bleed in spite of platelet-enhancing therapy. Clinical trials with long-term follow-up are needed, using clinical parameters as study endpoints, to answer the question of which subgroup of children with ITP should be treated upfront with platelet-enhancing therapy.