Severe malaria is an important cause of paediatric emergency admissions in Nigeria. It is also a significant cause of morbidity and mortality in Nigerian children. Knowledge of the manifestation and the predisposing factors to severe malaria is expected to provide information that will reduce its incidence and reverse the negative outcome of this disease. To document the incidence, manifestations, rate of use of right anti-malarial combination therapy and outcome of severe malaria, at the Paediatric Emergency Unit (PEU) of the Ladoke Akintola University of Technology Teaching Hospital, Osogbo. All children admitted into the PEU with severe malaria between the 1st April 2007 and 31st September 2007 were studied. The manifestation of severe malaria was noted and recorded in a proforma. The data on the age, sex, socio-demographic status, clinical features, intervals between symptom and presentation, outcomes and drugs used before presentation were also recorded. All the patients were treated with intra muscular Artemisin and oral Amodiaquine on admission. Of the 286 children admissions at the PEU over the 6 month period, 58 (20.3%) had severe manifestations of malaria. The 58 children consist of 34 boys and 24 girls giving a male to female ratio of 1: 0.7. Febrile convulsions, severe anaemia, persistent vomiting, jaundice, hypoglyceamia, cerebral malaria, prostration, hyperpyrexia and accidocis occurred in 23 (31.5%), 22 (30.1%), 13 (17.8%), 3 (4.1%), 3 (4.1%), 3 (4.1%), 3 (4.1%), 2 (2.8%) and 1 (1.4%) case, respectively. The mean duration of hospitalization was 3.2 days. Fever resolved in 50 (86.2%) subjects within 48 h of administration of ACT while on PEU admission. About 53 (91.4%) of the 58 children were discharged home in a satisfactory condition while 2 (3.4%) were discharged against medical advice and the remaining 3 (5.2%) died as a result of severe anaemia. These 3 deaths represent 15% of the total 20 mortalities recorded at PEU in the 6 month period. The right ACT was used by 5 (8.6%) of the 58 studied and ignorance concerning ACT was the reason given for non use among those who did not. Of the 4 subjects who consulted government owned hospitals prior to presentation, two used the correct ACT and 2 did not compared to the remaining 54 subjects who received treatment from left over home stock, patent medical stores, pharmaceutical shops and private hospitals of whom 3 used the correct ACT and 51 did not. ?2 = 4.55, p = 0.03 Yate’s correction applied. Severe malaria is an important cause of morbidity and mortality in Nigerian children. Febrile convulsions and severe aneamia are the most common presentations of severe malaria. The use of ACT’s was poor in this study. It is likely that the disease burden from severe malaria can be drastically reduced by the prompt administration of correct ACT, judging from the good response to ACT at the health facility of study.