Pediatric obstructive sleep apnea (OSA) is a multifactorial condition with serious neurocognitive, cardiovascular, and metabolic consequences. While adenotonsillectomy (AT) remains the first-line therapy for many cases, complex presentations involving obesity, craniofacial anomalies, or neuromuscular disorders require coordinated multidisciplinary management. This review provides a comprehensive synthesis of current strategies across diagnosis, treatment, and long-term follow-up. Diagnostic approaches include clinical screening with a combination of physical examination, polysomnography, imaging, and drug-induced sleep endoscopy. Treatment options range from surgical interventions to positive airway pressure therapy, pharmacologic treatments, dental and orthodontic approaches, behavioral modification, and psychological therapy. Special considerations are given to high-risk populations such as children with Down syndrome, Prader-Willi syndrome, neuromuscular disease, and extreme obesity. The emphasis is on residual or refractory OSA and the importance of individualized treatment pathways, shared decision-making, and multidisciplinary clinics. Longitudinal care—neurocognitive monitoring, cardiometabolic surveillance, and digital health tool use—is critical for optimizing long-term outcomes. By synthesizing evidence across specialties, this review provides practical guidance for comprehensive, patient-centered care in pediatric OSA.