Objective: Pediatric severe pneumonia is a life-threatening condition with high incidence and mortality rates. This study provides a comprehensive analysis of pathogen distribution, infection patterns, clinical manifestations, and prognosis associated with the disease. Methods: This study involved 227 children with severe pneumonia and a control group of 227 with non-severe pneumonia. Targeted next-generation sequencing (tNGS) was applied to identify respiratory pathogens. Results: The median age of children with severe pneumonia was 12 months, markedly younger than the median of 24 months in the non-severe group. The tNGS identified suspected pathogenic microorganisms in 99.12% of the severe pneumonia cases, with predominant pathogens including Human Respiratory Syncytial Virus (33.92%), Cytomegalovirus (33.04%), Mycoplasma pneumoniae (24.67%), and Rhinovirus (23.79%). Clinically, those with severe pneumonia exhibited markedly elevated procalcitonin levels and an increased prevalence of fever, wheezing, and dyspnea, alongside longer hospital stays, more protracted fever, and significantly higher hospitalization costs compared to their non-severe counterparts. Complications, including respiratory and other systemic issues, occurred in 96.04% and 59.47% of the severe pneumonia group, respectively, both significantly higher than in the non-severe pneumonia group; 99.12% required respiratory support and significantly more (56.83%) were admitted to the ICU, with a 9.69% incidence of poor outcomes. Conclusion: Children with severe pneumonia tend to be younger than those with non-severe pneumonia. While significant differences are observed in the distribution of pathogens, complications, clinical manifestations, and prognosis between the two groups, no significant differences are noted in the number of infecting microorganisms or infection patterns.