The goal of this pilot study is to explore the feasibility and acceptability of a medicinal cannabis clinical trial into easing the symptoms of children undergoing palliative care for non-oncological conditions. The trial will evaluate the study design including recruitment strategy, medication tolerability, duration and outcomes to determine acceptability and feasibility for participating families. The data collected will then be used to design a full-scale multi-centre trial.

Participants will be randomly allocated to receive one of two medicinal cannabis products. Neither the participants nor researchers will know the study drug allocation until the end of the trial.

This is a single site, double-blind, randomized, pilot study of 10 participants investigating two medicinal cannabis (MC) products in children aged 6 months to 21 years who are undergoing palliative care for non-oncological conditions. Eligible participants will be randomized 1:1 to receive one of two medicinal cannabis products (C12T12 or C20T5).

The primary objective of this pilot study is to evaluate all elements of the study design (recruitment strategy, study duration, study procedures, study medication tolerance and outcome measures) to assess if they are acceptable and feasible for the conduct of a full-scale randomised trial of MC to reduce symptom burden in paediatric patients undergoing palliative care for non-oncological conditions.

The secondary objective of this study is to collect preliminary data on the safety of two different oral MC oil formulations in this population.

Each participants will be involved in the trial for up to 100 days:

• Screening period: Up to 14 days
• Up-titration: day 1 to day 16
• Maintenance treatment period: day 17 to day 42
• Down-titration: day 43 (end of maintenance period clinic visit) to day 58
• Post-treatment follow-up: day 59 to day 86.

Inclusion Criteria:

1. Males and females aged 6 months to 21 years of age;

2. Receiving care in the Victorian Paediatric Palliative Care Program for a non-oncological condition;

3. Pain, dystonia and/or gut dysfunction parent-rated symptom score above threshold, defined by rating on the relevant revised Memorial Symptom Assessment Scale (MSAS) question(s) of:

   1. Frequency: "Frequently" or "Almost Constantly", AND
   2. Severity: "Moderate", "Severe", or "Very Severe", AND
   3. Distress: "Quite a bit", or "Very much";

4. No changes in medication or other interventions in the two weeks prior to randomization;

5. Participant and family have the ability to comply with the protocol requirements, in the opinion of the investigator;

6. Agrees not to drive for the duration of the study.

Exclusion Criteria:

1. Non-English speaking parents.
2. Participant history of psychosis, schizophrenia, bipolar disorder, or major depressive disorder, or a first degree family history of psychosis.
3. Taking medications which are known to interact with medicinal cannabis: warfarin, mTOR inhibitors (e.g sirolimus, tacrolimus), anti-cancer agents, citalopram >20mg/day, escitalopram >10mg/day.
4. Abnormal liver function tests defined as ALT > 3 x ULN
5. Current use of illicit drugs or medicinal cannabis, or use in the 4 weeks prior to screening
6. Pregnant or intending to become pregnant during the study, or breastfeeding.
7. History of clinically significant suicidal thoughts in the prior 12 months.
8. Life expectancy less than 3 months in the opinion of the investigators
9. Allergy to any of the components in the investigatory products (eg sunflower oil)
10. Diagnosis of a malignant condition

The de-identified data set collected for this analysis of the Pilot Study of MC in Paediatric Palliative Care will be available six months after publication of the primary outcome. The study protocol and analysis plan will also be available. The data must be obtained from the Murdoch Children's Research Institute. Prior to releasing any data the following are required: a data access agreement must be signed between relevant parties, the 'Pilot Study of MC in Paediatric Palliative Care' Study Management Group must see and approve the data analysis plan describing how the data will be analysed, there must be an agreement around appropriate acknowledgment and any additional costs involved must be covered. Should the Study Management Group be unavailable, this role is delegated to the Murdoch Children's Research Institute. Data will only be shared with a recognized research organisation which has approved the proposed analysis plan.

6 months after publication of primary outcome

1) Data access agreement; 2) approval by Trial Steering Committee; 3) recognized research institutions.