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Immune thrombocytopenia in childhood is usually an acute self-limiting disorder and despite very low platelet counts is rarely complicated by serious bleeding. Several surveys indicate that only 5% or fewer children experience serious bleeding, most commonly from the nose or gastrointestinal tract. Such children need urgent measures to control bleeding, both transfusion where necessary and pharmacotherapy to raise the platelet count. Not infrequently the response of the count is less than optimal. While intracranial hemorrhage is the most feared and serious complication, it is rare, occurring in about 0.3% of cases, and if treated promptly usually has a good outcome. Treatment prior to intracranial hemorrhage does not necessarily prevent it, and it may occur after many months of otherwise clinically mild disease. The relative risk increases with the length of time a child has a very low platelet count. An international registry will help to collect more information about these important cases. Menstrual bleeding can cause severe problems for adolescents and may need a multidisciplinary approach with hormonal manipulation of the menstrual cycle.