Objective：To explore the evaluation value of neutrophil to lymphocyte ratio（NLR）in the prognosis of Mycoplasma pneumoniae pneumonia（MPP）. Methods：A retrospective analysis was applied to 2 375 hospitalized children with MPP in Suqian Hospital Affiliated to Xuzhou Medical University from January 2019 to December 2023. According to the severity of the condition，the children were divided into severe MPP（SMPP）group（n=125）and non-SMPP group（n=2 250），or into refractory MPP（RMPP）group （n=451）and non-RMPP group（n=1 924）. The basic information and clinical data of all pediatric patients were collected to assess the prognostic value of NLR in SMPP and RMPP. Results：NLR was an independent predictor of SMPP（OR=1.188，95% CI：1.123-1.299， P=0.033）. Compared with children with a low NLR，children with a high NLR had a higher incidence of SMPP（P ＜ 0.001）. NLR was also an independent predictor of RMPP（OR=1.320，95%CI：1.145-1.432，P ＜ 0.001）. Children with a high NLR were more likely to develop SMPP and RMPP as well as had higher ICU hospitalization rate，total fever duration，longer hospital stays，and higher hospitalization costs，compared those with a low NLR（P ＜ 0.001）. Conclusion：NLR may be used to independently predict the prognosis of MPP and provide guidance for early treatment of SMPP and RMPP.