This study retrospectively analyzed 417 children hospitalized with *Mycoplasma pneumoniae* pneumonia (MPP) between January and December 2022, focusing on the outcomes of severe MPP (SMPP). The study found that 50.6% (211/417) of the children had SMPP, with a peak incidence in winter. Among the 211 children with SMPP, 210 were treated and discharged with improvement, while one child with congenital heart disease died of cardioembolic stroke. Patients with SMPP had significantly higher rates of underlying diseases, extrapulmonary complications (myocardial and digestive system involvement), and bacterial co-infections. A total of 25 (12%) children required mechanical ventilation, with a median duration of 3 days. All children were treated with macrolide antibiotics, but a higher proportion of SMPP patients received additional treatments such as antibiotics other than macrolides, methylprednisolone sodium succinate, intravenous immunoglobulin, and anticoagulation. Laboratory tests showed that SMPP patients had significantly higher levels of white blood cells, neutrophils, C-reactive protein, procalcitonin, and various cytokines (IFN-γ, IL-2, IL-5, IL-6, IL-8, IL-10), and lower percentages of lymphocytes, monocytes, and natural killer cells. Co-infections, particularly bacterial and viral, were more common in SMPP patients. The study concluded that severe MPP in children is characterized by more pronounced inflammatory reactions and extrapulmonary complications, and that hormonal, prophylactic, and anticoagulant therapies, along with the use of antibiotics other than macrolides for bacterial co-infections, should be incorporated into treatment regimens.This study retrospectively analyzed 417 children hospitalized with *Mycoplasma pneumoniae* pneumonia (MPP) between January and December 2022, focusing on the outcomes of severe MPP (SMPP). The study found that 50.6% (211/417) of the children had SMPP, with a peak incidence in winter. Among the 211 children with SMPP, 210 were treated and discharged with improvement, while one child with congenital heart disease died of cardioembolic stroke. Patients with SMPP had significantly higher rates of underlying diseases, extrapulmonary complications (myocardial and digestive system involvement), and bacterial co-infections. A total of 25 (12%) children required mechanical ventilation, with a median duration of 3 days. All children were treated with macrolide antibiotics, but a higher proportion of SMPP patients received additional treatments such as antibiotics other than macrolides, methylprednisolone sodium succinate, intravenous immunoglobulin, and anticoagulation. Laboratory tests showed that SMPP patients had significantly higher levels of white blood cells, neutrophils, C-reactive protein, procalcitonin, and various cytokines (IFN-γ, IL-2, IL-5, IL-6, IL-8, IL-10), and lower percentages of lymphocytes, monocytes, and natural killer cells. Co-infections, particularly bacterial and viral, were more common in SMPP patients. The study concluded that severe MPP in children is characterized by more pronounced inflammatory reactions and extrapulmonary complications, and that hormonal, prophylactic, and anticoagulant therapies, along with the use of antibiotics other than macrolides for bacterial co-infections, should be incorporated into treatment regimens.