• Maria Laura Requena, Madeline Avery, Angela M Feraco, Luciano G Uzal, Joanne Wolfe, and Veronica Dussel.
• Center for Research and Implementation in Palliative Care, Institute for Clinical Effectiveness and Health Policy (M.L.R., L.G.U., V.D.), Buenos Aires, Argentina.
• J Pain Symptom Manage. 2022 Apr 1; 63 (4): 548-562.

ContextChildren, adolescents and young adults with cancer continue to experience significant symptom suffering throughout their illness.ObjectivesTo identify barriers to effective symptom management in pediatric advanced cancer.MethodsUsing a qualitative multiple case study we refined the Pediatric Quality of Life and Evaluation of Symptoms Technology Response to the Pediatric Oncology Symptom Experience (PediQUEST Response), a pediatric palliative care (PPC) intervention. Twenty-three children aged ≥2 years old with advanced cancer, their parents and primary and PPC clinicians were enrolled. Children and parents reported symptoms weekly over 4-months using the Memorial Symptom Assessment Scale (MSAS) administered by an electronic system (PediQUEST). When symptom distress episodes (SDEs) were reported (MSAS symptom score ≥33) we studied symptom management processes using interviews of family members/clinicians, and chart abstractions. Data were coded and analyzed using grounded theory and NVivo software.ResultsChildren reported 308 SDEs within 193 surveys and parents 529 SDEs in 165 surveys administered. We conducted 85 and 88 interviews with families and clinicians respectively. While we confirmed the presence of known barriers, we identified a prominent theme, that symptoms were "normalized." Patients, parents, and all clinicians, including PPC specialists, got accustomed to high symptom burden and lacked expectations that distress could be alleviated. We defined "normalization of symptoms," as the process by which symptom related suffering is appraised as unavoidable.ConclusionNormalization of symptoms is a pervasive barrier enacted by all involved in caring for children with advanced cancer. Strategies to overcome normalization are critical to ease child distress.Copyright © 2021 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

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