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This study evaluated the efficacy and safety of doxycycline in treating Severe Mycoplasma pneumoniae Pneumonia (SMPP) in children under eight years old through clinical analysis and meta-analysis. A total of 92 pediatric SMPP cases were divided into a doxycycline treatment group (44 cases) and a macrolides control group (48 cases). Compared to the control group, the doxycycline group exhibited significantly shorter cough relief time (5.4 ± 1.2 vs. 7.2 ± 1.6 days, p < 0.05) and pulmonary rale resolution time (6.2 ± 1.3 vs. 8.0 ± 1.7 days, p < 0.05). The overall treatment efficacy rate was higher in the doxycycline group (88.6% vs. 75.0%, p < 0.05). No significant differences were found in fever resolution time or hospitalization duration (p > 0.05). Safety analysis revealed comparable adverse event rates between groups (18.2% vs. 16.7%, p > 0.05), primarily mild rash and gastrointestinal discomfort, with no tooth discoloration observed. The meta-analysis confirmed the advantages of doxycycline, demonstrating superior treatment efficacy (RR: 0.68, 95% CI: 0.58-0.79), shorter fever resolution (MD: - 1.5 days, 95% CI: - 2.3 to - 0.7), and faster cough and pulmonary rale resolution. Adverse events were similar across groups. These findings highlight doxycycline's clinical efficacy and safety in SMPP treatment, providing strong evidence for its application in pediatric practice.