The many publications about ITP that extol or refute the necessity of drug treatment clearly agree that: (1) life-threatening hemorrhage is uncommon and difficult to predict and (2) retrospective studies, registry databases, and the small, randomized trials have failed to identify which patients truly need drug therapy. Would a large, randomized, prospective clinical trial-which included an "observation-only" subset-quell this controversy? Proving in a clinical trial whether drug treatment prevents serious hemorrhage would be a major task. Newer tools, such as clinical hemorrhage scoring  and proteome and genome arrays, may help to identify clinical and molecular susceptibility markers, and therefore, unravel the dilemma of predicting which children who have ITP will experience life-threatening hemorrhage. These susceptible children could then be candidates for clinical trials that evaluate the prevention of severe bleeding with drug therapy. For the moment, physicians who manage ITP in children must digest the available medical evidence and use their own clinical judgment when deciding if and how to intervene.
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