About 20% of the children diagnosed with acute idiopathic thrombocytopenic purpura (ITP) will run a chronic course. Only in a minority of these, platelet-count-enhancing treatments are indicated. Most treatment options are directed at decreasing platelet destruction including corticosteroids, intravenous immunoglobulins, splenectomy, and other immunosuppressive or immune modulating drugs. In children, rituximab seems to have similar efficacy as in adults with a lasting continuous remission rate of 30–35%. Toxicity includes fever, pruritus, throat tightness, and serum sickness that may be reason to discontinue rituximab treatment. No increased frequency of infections is noted. We conclude that rituximab should be given to those symptomatic ITP patients who would otherwise be referred for splenectomy; only those who fail rituximab treatment should proceed to surgery. Pediatr Blood Cancer 2006;47:714–716. © 2006 Wiley-Liss, Inc.