OBJECTIVE To determine current practices in neonatal intensive care units (NICUs) of managing postoperative pain, pain associated with nonsurgical procedures and disease-related pain. METHODS Retrospective, self-administered descriptive mail survey. METHODS Level 3 NICUs in Canada. METHODS The head nurses of the 30 Canadian level 3 NICUs in February 1992; 26 (87%) responded. METHODS Five-point Likert scale of Always (in 100% of cases), Often (in 75% to 99%), Usually (in 25% to 74%), Rarely (in 1% to 24%) and Never (in 0%). Selected items were validated through a chart review. RESULTS Opioids were used postoperatively always or often in 93% (13/14), 88% (15/17) and 65% (11/17) of the NICUs that cared for neonates having undergone cardiac, major and minor surgery respectively. Most of the NICUs did not use paralysis or sedation alone for postoperative pain management. Local anesthesia was used always or often for emergent chest tube placement in 16% (4/25) of the NICUs, for elective chest tube placement in 48% (12/25) and for lumbar puncture in 12% (3/24). An analgesic was rarely or never used for insertion of a tracheal tube in emergent situations in 88% (23/26) of the NICUs and in elective situations in 84% (21/25); the corresponding figures for sedative use were 85% (22/26) and 73% (19/26). Only 22% (5/23) used opioids regularly in cases of nonsurgically managed necrotizing enterocolitis. Physicians alone determined the rate of opioid weaning in 54% (13/24) of the NICUs. Opioids were usually described as being weaned as tolerated. CONCLUSIONS Analgesic use for the management of postoperative pain in neonates having undergone cardiac and major surgery is frequent but continues to be infrequent in the postoperative care of patients having undergone minor surgery in some NICUs. Procedural and disease-related pain is frequently untreated or undertreated. Guidelines for establishing a protocol to manage pain in NICUs are given.