The palliative care needs of infants, children and young people differ to those of adults. The broad spectrum of paediatric life-limiting or life-threatening conditions mean that symptoms are varied and complex to manage. The UK National Institute for Health and Care Excellence (NICE) has emphasised pain management in paediatric palliative care as a research priority. This is the first systematic review and meta-analysis to investigate and report on the barriers and facilitators experienced by carers and healthcare professionals when managing paediatric symptoms at end of life. Healthcare professionals’ attitudes, treatment and its side effects, place of care and families’ own symptom management strategies all impact on family caregivers’ ability to manage symptoms. Barriers and facilitators to symptom management for healthcare professionals include medicine access, treatment efficacy and side effects, specialist support, training and education, health services delivery and home care.