Sacral dimple

Template

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DimpleChoose one

Other skin markers presentChoose any

Other skin markers absentChoose any

Bowel and bladderChoose one

Neuro examChoose one

PlanChoose any

Follow-upChoose one

Counseling

A small dimple low on the back is common and usually harmless. Recommended supportive care with an emphasis on gentle cleaning of the area during diaper changes. Return precautions given including leg weakness, changes in stooling or urination, drainage or redness at the dimple, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

CounselingNot in the note with these choices

Imaging checks whether the dimple connects to the spinal cord, which is uncommon. Recommended supportive care with an emphasis on gentle cleaning of the area. Return precautions given including leg weakness, changes in stooling or urination, drainage or redness at the dimple, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

Note when inserted as is

Sacral dimple
• Simple sacral dimple: small, midline, within the gluteal cleft, with a visible base
• No hair tuft, hemangioma, skin tag, deviated gluteal cleft, or lump under the skin
• Normal stooling and urination
• Normal lower extremity strength, tone, and reflexes
• No imaging needed given a simple dimple and normal exam
• Follow up as needed

A small dimple low on the back is common and usually harmless. Recommended supportive care with an emphasis on gentle cleaning of the area during diaper changes. Return precautions given including leg weakness, changes in stooling or urination, drainage or redness at the dimple, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

Return precautions in the template

leg weaknesschanges in stooling or urinationdrainage or redness at the dimple

Sources

AAP Clinical Practice Guideline for Diagnosis and Management of Faltering Weight. Pediatrics 2026;157(4):e2025075764
AAP Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics 2022;150(1):e2022057988. Recommendations read
Thomas J et al; AAP Section on Breastfeeding. Identification and Management of Ankyloglossia and Its Effect on Breastfeeding in Infants: Clinical Report. Pediatrics…
Shaw BA, Segal LS; AAP Section on Orthopaedics. Evaluation and Referral for Developmental Dysplasia of the Hip in Infants. Pediatrics 2016;138(6):e20163107.…
Krowchuk DP et al. Clinical Practice Guideline for the Management of Infantile Hemangiomas. Pediatrics 2019;143(1):e20183475. Highlights and selected KAS read
AAP Clinical Report: Prevention and Management of Positional Skull Deformities in Infants (Laughlin, Pediatrics 2011;128(6):1236). Retired February 2018 (not…

Few formal guidelines cover this topic, so the template also leans on expert opinion.