1. INTRODUCTION Tramadol is a synthetic centrally acting analgesic, which has two stereoisomers with dual mechanism of action-opioid and monoaminergic. Its major metabolite O-desmethyl tramadol -opioid receptors (MORs) as an agonist. The monoaminergic activity of tramadol acts synergistically on serotonergic and noradrenergic mechanisms of pain transmission. More specifically, tramadol enhances spinal pain inhibitory pathways by inhibiting neuronal re-uptake of serotonin (5-hydroxytryptamine [5- HT]) and noradrenaline, stimulating 5-HT release.[1] Tramadol poisoning is rare in children because it is not commonly used for children. Common presentations include respiratory and central nervous system (CNS) depression.[2] However, we highlight the case of a 4-year-old boy,who in addition to the above-mentioned presented with hypoglycemia.