BACKGROUND: The prevalence of neonatal oropharyngeal dysphagia (OPD) in high-risk infants in lower-middle-income countries is unknown. Objectives: To determine the prevalence and associated risks for OPD in high-risk neonates in order to allow timely intervention for OPD, minimising negative outcomes. METHOD: A prospective cross-sectional observational study was conducted in an urban hospital in South Africa. Clinical feeding assessments were conducted using the Neonatal Feeding Assessment Scale with all available neonates in neonatal care. RESULTS: The sample of 81 high-risk neonates (mean chronological age = 11.7 days; standard deviation = 15.6 days) had been feeding orally for 2 days and were approaching discharge. Fifty-two participants (64.2%) had OPD. Risks likely associated with OPD included breech presentation, septicaemia and other infections, spending more than 1 day on a warm table or incubator, neurological conditions, prenatal exposure to maternal smoking, siblings withmental or neurological disability, participants with congenital disorders, preterm birth (<37 weeks), low birth weight (< 2500 g), or retinopathy of prematurity. CONCLUSION: An unexpected high prevalence of OPD was found in neonates already deemed ready for oral feeding and approaching discharge. Timely early involvement of the Speech-Language Therapists (SLTs) in decision-making about feeding readiness may prevent serious complications of neonatal OPD. Findings may inform South African neonatal clinicians. The study provides motivation for early intervention from SLTs before the infant and mother are discharged from high care and dispersed to communities where intervention services may be scarce.