〔Abstract〕 To investigate the clinical characteristics and risk factors of Mycoplasma pneumoniae pneumonia (MPP) based on a dual classification integrating imaging features and clinical severity. Methods Medical records of 2054 pediatric patients with MPP were retrospectively analyzed. The cohort was stratified into severe consolidation (n=253), severe non-consolidation (n=118), non-severe consolidation (n=393), and non-severe non-consolidation groups (n=1 290) based on clinical and radiological findings. Inter group data and characteristics were compared and multiple regression analysis was conducted to construct a prediction model for severe consolidation group. Results Significant differences were observed among the groups in terms of age, duration of fever, length of hospital stay, presence of pulmonary rales, inflammatory markers (CRP, LDH), the use of hormones, and bronchoscopic treatment (all P < 0.05). Compared with the severe non-consolidation group, non-severe consolidation group, and non-severe non-consolidation group, children with severe consolidation pneumonia caused by MPP exhibited the longest duration of fever [8 (6, 11) days vs 6 (2, 9), 7 (6, 9) and 6 (3, 8) days, respectively] and the longest length of hospital stay [7 (5, 8) days vs 6 (5, 8), 6 (5, 8) and 6 (4, 7) days, respectively]. They also had the highest incidence of reduced breath sounds [34 cases (13.4%) vs 2 cases (1.7%), 29 cases (7.4%) and 13 cases (1.0%), respectively] and a substantially higher rate of coinfections, particularly viral infections [63 cases (24.9%) vs 23 cases (19.5%), 60 cases (15.3%) and 190 cases (14.7%), respectively]. Multivariate analysis indicated that the independent risk factors for severe MPP (SMPP) were age > 4.5 years, length of hospital stay > 6.5 days, reduced breath sounds, neutrophil-to-lymphocyte ratio (NLR) > 1.66, LDH > 370.5 u/L, CRP > 9.5 mg/L, and coinfection with viruses. Reduced breath sounds (OR = 5.58, 95% CI: 2.45 - 12.69) and coinfection with bacteria (OR = 3.11, 95% CI: 1.43 - 6.75) were identified as the most significant risk factors for pulmonary consolidation in non-severe MPP children. Additionally, reduced breath sounds, coinfection with viruses, LDH > 365.5 u/L, and CRP > 32.1 mg/L were risk factors for severe pneumonia in children with pulmonary consolidation. For non-consolidation MPP children, the presence of pulmonary dry rales (OR = 2.28, 95% CI: 1.46 - 3.56) was the primary independent risk factor for the development of severe pneumonia. Conclusion The chest imaging findings of MPP are associated with clinical severity, and the risk factor model constructed based on this imaging-clinical classification can assist in achieving precise hierarchical diagnosis and treatment in clinical practice.