Background: Comprehensive care for children with medical complexity and/or life-limiting illness often requires symptom management (e.g. pain, nausea, dysautonomia) and can include end-of-life care, all of which can be challenging for pediatricians in training. Though these primary palliative care skills are commonly taught on dedicated palliative care rotations, it is unknown how comfortable pediatric residents are utilizing these skills. Our objectives were to assess pediatric residents’ comfort providing this care and to identify their needs for related educational resources. Methods: We invited all residents (N = 120) in a large pediatrics residency to complete an anonymous online survey designed by the study authors, who have expertise in palliative care and medical education. Participation was voluntary and took place in the final quarter of an academic year. We asked participants to rate comfort managing symptoms on a 5-point Likert scale (1 = extremely comfortable; 5 = extremely uncomfortable) and to report if they had access to management resources. Results: Seventy-five residents began the survey, 64 of whom answered all questions. All post-graduate year (PGY) training levels were represented (PGY1 = 36%, PGY2 = 38%, PGY3+ = 26%). Though the majority reported comfort with management of dysautonomia (57%) and refractory nausea (66%), fewer felt comfortable managing pain (using opioids {47%} and patient-controlled analgesia {PCA, 37%}) and providing end-of-life care (33%). Residents’ comfort managing end-of-life care and refractory nausea did not vary significantly by training level, though comfort with managing pain using opioids and PCA, and dysautonomia was significantly lower for PGY1 residents compared to those at PGY3+ levels (p < 0.05). Residents who had completed a palliative care rotation reported significantly greater comfort managing dysautonomia, pain using opioids (including PCA), end-of-life care, and refractory nausea (p < 0.05). The majority indicated they did not have access to resources to help them manage dysautonomia (68%), end-of-life care (56%), and nausea (58%), though a small majority indicated access to opioid and PCA pain management resources (57%). Most reported they would be extremely likely to reference a point-of-care printed symptom management guide (64%). Conclusion: Pediatric residents’ comfort with primary palliative care symptom management varied by symptom, level of training, and prior participation in a palliative care rotation. Comfort providing end-of-life care was low and did not vary by training level. The majority of residents reported not having available resources to help them manage these symptoms, identifying educational targets to improve care for children with complex symptom management needs. These data suggest that providing access to palliative care rotations and point-of-care symptom management resources should be a priority for pediatric residency programs.