Abstract: Objective To evaluate the application of neutrophil to lymphocyte ratio (NLR) as a marker in the diagnosis and prediction of refractory Mycoplasma pneumoniae pneumonia (RMPP) in children. Methods A total of 142 patients with Mycoplasma pneumoniae pneumonia (MPP) who were admitted to the Second Department of Respiratory Medicine, Xuzhou Children's Hospital from January 2021 to December 2021 were selected and their clinical data were retrospectively analyzed. They were divided into two groups: a common MPP group (n=101) and a RMPP group (n=41). Both groups were compared for clinical data, white blood cell (WBC), neutrophil (NEU), platelet (PLT), NLR, C-reactive protein (CRP) and procalcitonin (PCT). A receiver operating characteristic curve (ROC) was plotted to determine the cut-off values of three biomarkers with statistical significance. Logistic regression analysis was performed to identify the independent predictors of RMPP. Results Children in both groups presented cough, while no statistical difference was found in sex between the two groups (P>0.01). There were statistical differences in age, fever, NEU, NLR and CRP between the RMPP group and the MPP group (all P<0.01). The area under the ROC (AUC) of NLR in diagnosing RMPP patients was 0.854, with a specificity of 79.2% and a sensitivity of 87.8%. According to the binary logistic regression analysis, NLR, NEU and CRP were the independent risk factors for RMPP (all P<0.01), with a relative risk range of NLR>CRP>NEU. Conclusions NLR can be used as an indicator for the diagnosis and prediction of RMPP.