Paediatric obstructive sleep apnoea and early cardiovascular risk phenotypes: an evidence review

Adult obstructive sleep apnoea (OSA) is an established cardiovascular risk factor, but paediatric OSA has been framed mainly around neurocognition and growth. We reviewed PubMed, Ovid-Embase and Web of Science (2000-2026), prioritising eligible paediatric studies with quantifiable outcomes (ambulatory/office blood pressure (BP), autonomic indices/heart-rate variability, endothelial function/arterial stiffness, carotid intima-media thickness (cIMT) and echocardiographic structure/function) and key interventional data. Across cohorts, 24-h ambulatory blood pressure monitoring (ABPM) most consistently demonstrates higher nocturnal BP and reduced dipping; emerging exposure metrics such as hypoxic burden (the integrated depth and duration of oxygen desaturation across sleep) may capture physiological stress better than the apnoea-hypopnoea index alone. Autonomic imbalance, including sympathetic predominance, altered sleep-stage autonomic modulation and reduced baroreflex gain, provides a plausible bridge between respiratory events and early vascular/cardiac remodelling, and often improves after adenotonsillectomy. Vascular data suggest early functional abnormalities (endothelial reactivity, wave reflection/central haemodynamics) with smaller and inconsistent differences in structural markers, such as cIMT, strongly modified by obesity and development. Cardiac studies most reproducibly show increased left-ventricular mass/geometry and impaired diastolic relaxation, while right-heart and pulmonary vascular signals appear most relevant in selected higher-risk groups. Treatment effects appear more readily detectable in autonomic/endothelial measures than in office BP over short follow-up, reinforcing ABPM as a preferred research and selected high-risk clinical end-point. Paediatric OSA should therefore be approached through an early-risk framework, including identifying higher-risk phenotypes, quantifying nocturnal haemodynamic burden when feasible and integrating OSA therapy with weight and guideline-directed BP management.