Over the years pediatric hematologists have continued to debate whether pharmacotherapy or clinical observation should be employed as initial management in childhood immune thrombocytopenia (ITP). Delineating the fundamental elements of heterogeneity in bleeding manifestations in childhood ITP has proven to be a complicated task. Efforts to classify the impact of hemorrhage in ITP based on platelet count have been problematic. Factors beyond relying on a laboratory measurement as a surrogate marker of disease severity need to be considered. What is needed to better guide therapeutic decision-making is a clinically relevant and evidence-based measure of bleeding severity. In this special supplement, the history of therapeutic management in ITP and prior attempts to grade or quantify hemorrhage will be reviewed.