OBJECTIVE: To identify clinical features associated with unsuccessful medical therapy in children with deep space neck infections (DSNIs). STUDY DESIGN: Consecutive case series with chart review. SETTING: Tertiary-care, academic children's hospital. SUBJECTS AND METHODS: One hundred seventy-eight pediatric patients treated for retropharyngeal or parapharyngeal infections between July 1, 2007, and May 23, 2012. RESULTS: Median age was 34.5 months (2.9 years; range, 2-142 months); two-thirds were male. Increased surgical drainage was found in children age ≤ 15 months (P = .002) and for abscesses >2.2 cm (P = .0001). Risk factors associated with increased likelihood of medical therapy failure included age ≤ 51 months, intensive care unit admission, and computed tomography findings consistent with abscess size >2.2 cm. Methicillin-resistant Staphylococcus aureus infections were found more often in younger children, with the highest incidence in those ≤ 15 months of age (P = .001). All children had resolution of infection. CONCLUSION: Deep space neck infections in children can often be successfully managed with medical therapy alone, but life-threatening complications may occur. We recommend that young patients be managed cautiously.