Background <p>Children and adolescents with life-limiting conditions (LLCs) often face distressing medical procedures, prolonged hospital stays, and other challenges, leading to heightened anxiety and psychological distress. To address these symptoms, psychological interventions using modern technologies like immersive virtual reality are recommended alongside traditional treatments. While virtual reality (VR) has shown promise in reducing distress in various pediatric groups, its use in pediatric palliative care (PPC) is still emerging. The aim of this study was to assess the feasibility, acceptability and effectiveness of experiential VR intervention and compare it with a second distraction method in the form of a video in a population of pediatric patients with LLC.</p> Methods <p>This pilot randomized control trial used a crossover design with a pre- and post- intervention assessment of anxiety, fear, and pain using standardized scales. Post-session patient-reported data were also collected using supplementary items. A total of eighteen pediatric patients (8 girls, 11–17 years of age;10 boys, 10 − 17 years of age) participated in the study, randomized into two groups. The experimental group (<i>N</i> = 10) received VR in both sessions, while the control group (<i>N</i> = 8) experienced a passive video in the first session, followed by VR in the second. Given the characteristics of the sample, non-parametric statistical analyses were conducted using the Mann-Whitney U test and Wilcoxon signed rank test.</p> Results <p>The findings showed that VR distraction produced a statistically significant reduction in anxiety on all three occasions it was administered across both groups (experimental group: <i>p</i> = 0.028, <i>r</i> = 0.773; <i>p</i> = 0.049, <i>r</i> = 1.000; control group: <i>p</i> = 0.028, <i>r</i> = 0.905), demonstrating a consistent effect across the sample. Video distraction showed a trend toward anxiety reduction that did not reach statistical significance (<i>p</i> = 0.091), while producing a significant reduction in pain (<i>p</i> = 0.027). Among participants who received both interventions, VR was rated as significantly more enjoyable than video distraction (<i>p</i> = 0.036, <i>r</i> = -1.00). Most participants wanted to be distracted during the procedure (91%), felt that it decreased their anxiety (73%), found the VR system easy to use (96%), and wanted to use it again in future care (88%).</p> Conclusions <p>These exploratory findings from a pilot RCT provide preliminary evidence that VR distraction may serve as a feasible, acceptable, and potentially efficacious complementary approach for managing anxiety in children and adolescents with life-limiting conditions. While video distraction produced broadly comparable outcomes across measures, a differential pattern was observed for the predefined primary outcome of anxiety, which warrants confirmation in a future adequately powered trial. These findings highlight the potential of distraction-based interventions to provide meaningful therapeutic benefit in this population. The significantly higher enjoyment ratings for VR and its strong acceptability further support its potential clinical value in pediatric palliative care, where positive experience and engagement are central to quality of life. Nevertheless, the practical burden of implementation and associated costs require further investigation before definitive recommendations can be made.</p> Trial Registration <p>The study was registered retrospectively 8.1. 2025 (ISRCTN50308167).</p>