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To determine the incidence of and factors predicting management strategies used for procedural pain in Canadian neonatal intensive care units and to determine whether the incidence of procedures and their management has changed since our 1997 study.Five hundred eighty-two neonates who were hospitalized in any of the participating study centers were included.A prospective observational study was conducted in 14 Canadian neonatal intensive care units (level III A and III B). Infants were followed for 1 week regarding all invasive procedures. Data were collected prospectively by unit staff using a checklist and verified by research assistants.A total of 3508 tissue damaging (mean=5.8, SD=15) and 14,085 (mean=25.6, SD=15) nontissue damaging procedures were recorded. Half of procedures (46% tissue damaging and 57% nontissue damaging) had no analgesic interventions. Opiates were used for 14.5% of tissue-damaging procedures and sweet taste was used for 14.3% of the tissue-damaging procedures. Factors predicting use of pharmacologic management of tissue-damaging procedures were being less ill at birth, receiving high frequency ventilatory support, and being transferred to the study center. Parental presence predicted use of sweet taste or nonpharmacologic analgesia for tissue-damaging procedures. Study site practices varied widely with 1 unit providing analgesia for 90% of tissue-damaging procedures.Although the number of tissue-damaging procedures has decreased from 1997 and the use of analgesics has increased, the management of these procedures falls far below the recommended guidelines of the Canadian Pediatric Society. That 1 unit reached a high level of analgesic use suggests that it is possible to achieve this goal. That parental presence had a positive influence on comfort strategies supports offering encouragement and support for parents to remain with their infant during procedures.