The objective of this study was to determine treatment strategies for children admitted with pleural empyema. We reviewed the medical records of 93 consecutive patients with pleural empyema who presented in the last three years. Mean age was 3.8 years (range 3.5 months to 14 years) and the male to female ratio was 52:41. The left side was involved in 51 (54.8%) cases and there was only one case with bilateral effusion. After the chest X-ray and analysis of pus obtained by thoracocentesis, the initial treatment modality was chest tube drainage in 81 (87%) patients. Children required chest tube drainage for an average of 11.9 +/- 4.8 days. Out of the 81 children, 6 needed thoracotomy due to organized pleural fluid and another 4, who developed loculated pleural effusions, were treated with intrapleural urokinase (UK) administration. Twelve children, who had a delayed presentation with organized loculated pleural fluid and pleural thickening, underwent decortication and one, who was found to have a foreign body, found during surgery, needed an upper lobe resection. Medical management with adequate chest tube drainage and appropriate antibiotics has resulted in full resolution in the majority of patients with empyema. In cases of loculated pleural effusions identified at the early stages of the chest tube drainage, intrapleural UK administration was found to be a safe and efficient treatment modality. Thoracotomy should be reserved for late and organized empyema cases.