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While there are many guidelines for the ED evaluation of febrile children, these are largely derived and validated in high-resource settings. There is limited literature documenting recommended or actual management in resource-limited settings. We describe the presentation, diagnostic evaluation, treatment, and ED diagnoses of febrile children under 5 years old presenting to an urban emergency department in Dar es Salaam. Methods: This was a prospective observational study of children under 5 with fever or reported fever at Muhimbili National Hospital (MNH) ED. Treating physicians prospectively completed a standardized data form. Results: We enrolled 105 children, median age 14 months, with 80% >6 months, and 64% male. Presenting symptoms included poor feeding (47.6%) vomiting (42.9%), cough (34.3), difficulty breathing (28.6%), and diarrhoea (22.9%). 78% had vital sign abnormalities and 82% had abnormal physical examination. Among those undergoing point-of care testing, 11/105 tested (10.5%) had hypoglycaemia, 9/103 (8.7 %) were malaria positive, 17/30 (56.7%) had positive urine dipstick testing, and 5/26 tested (19.2%) were HIV positive. Laboratory-based tests included CBC and chemistry (each performed in 95.2%), VBG (56.2%), CSF (5.7%), blood culture (5.7%), urine culture (10.5%), CSF culture (1.9%), and CXR of chest (25.7%) and abdomen (3.8%). Interventions included antibiotics (70%), antimalarial (12%), IV fluids (54%), and antipyretics (41%). Top ED diagnoses included malaria (24.3%), pneumonia (15.2%), septicaemia (9.5%), urinary tract infections (7.6%), acute watery diarrhoea with dehydration (6.7%), meningitis (4.8%), anaemia (4.8%), skin and soft tissue infections (4.8%), bowel obstructions (3.8%), and pulmonary tuberculosis, sickle cell disease, and hepatitis (2.9% each). Laboratory-based tests were often abnormal; culture results were often unavailable; Conclusion: A wide range of presentations and management were documented. There was a high rate of positive diagnostic test results. Malaria and pneumonia were top diagnoses, but a wide range of infections were diagnosed.