Résumé : Introduction: This study aimed to determine the influence of the age and the level of malaria transmission on the clinical and biological expression of severe malaria in children. Methods: A prospective descriptive study was conducted in nine referral hospitals in Kinshasa. A total of 1350 children, less than 15 years old and hospitalized for severe malaria, were progressively included in the study between January and November 2011. Results: The majority of these children (74.5%) were less than 5 years of age. Major syndromes were severe anemia (11.4%), cerebral malaria (27.1%), and respiratory distress (20.5%). Severe anemia and cerebral malaria were associated with the age of the child and not the area transmission. On the other hand, respiratory distress was associated with high malaria transmission areas (P < 0.05). After adjustment, these associations were maintained. High malaria lethality was observed in the group of children aged 12-59 months (11.6%) and those from areas of high malaria transmission (8.4%). Conclusion: The child's age and level of transmission are associated with certain severe types of childhood malaria. Early and appropriate support would reduce the most fatal consequences associated with severe childhood malaria.