Background: Plasma Epstein–Barr virus (EBV) DNA has been determined as a prognostic factor in adult nasopharyngeal carcinoma (NPC) patients. This study was designed to evaluate the prognostic value of plasma pretreatment EBV DNA in children and adolescent NPC patients receiving intensity-modulated radiotherapy (IMRT).Methods: Pretreatment EBV DNA was retrospectively assessed in 147 children with newly diagnosed, non-metastatic NPC. All patients were treated using IMRT. Receiver operating characteristic (ROC) curve was used to identify the optimal EBV DNA cutoff point. Prognostic value was examined using a multivariate Cox proportional hazards model.Results: The median follow-up for the entire cohort was 58 months (range, 10–119 months), and the 5-year survival rates for all patients were as follows: overall survival (OS), 88.7%; locoregional relapse-free survival, 95.2%; distant metastasis-free survival (DMFS), 84.8%; and disease-free survival (DFS), 81.5%. For ROC curve analysis, the optimal cutoff value of pretreatment EBV DNA load for DFS was 40,000 copies/mL. High plasma EBV DNA was significantly associated with poorer 5-year DMFS (70.6 vs. 89.1%, P = 0.003) and DFS (63.9 vs. 86.9%, P < 0.001). In multivariate analysis, high plasma EBV DNA was an independent predictor for DMFS and DFS.Conclusions: Pretreatment EBV DNA level was a powerful prognostic discriminator for DMFS and DFS in children and adolescent NPC patients treated with IMRT.