INTRODUCTION: The study aimed to evaluate the efficacy of zinc supplementation, in addition to standard antimicrobial therapy, in the treatment of severe pneumonia among hospitalized rural Indian children aged 2-24 months. It also sought to identify factors associated with the development of pneumonia in this population. METHODOLOGY: A hospital-based, randomized, double-blinded, placebo-controlled trial was conducted from September to December 2022, registered with the Clinical Trial Registry of India (CTRI/2022/09/046070). A total of 94 children with severe pneumonia were randomly assigned to receive either 10 mg of zinc gluconate (2.5 ml) or a placebo twice daily during hospitalization, along with standard therapy. Clinical signs, symptoms, and laboratory parameters were monitored, and baseline characteristics were compared between the groups. RESULTS: The median duration of cough and cold in the Zinc group was significantly shorter compared to the Control group (p = 0.013, p = 0.005, respectively). Among stunted children, those in the Zinc group required about 3.12 fewer days for recovery compared to those in the Control group, and this difference was statistically significant (p = 0.05). However, no statistically significant differences were observed between the groups in the duration of tachypnea, hypoxia, chest indrawing, inability to feed, lethargy, severe illness, or overall hospitalization. CONCLUSION: While zinc supplementation demonstrated potential benefits such as reduced hospital stay and faster symptom resolution, these differences were not statistically significant. Further research is needed to validate zinc role in improving clinical outcomes in severe pediatric pneumonia.