26Holoprosencephaly (HPE), a defect in midline patterning of the forebrain and midface, arises ~1 27 in 250 conceptions. It is associated with predisposing mutations in the Nodal and Hedgehog 28 (HH) pathways, with penetrance and expressivity graded by genetic and environmental 29 modifiers, via poorly understood mechanisms. CDON is a multifunctional co-receptor, including 30 for the HH pathway. In mice, Cdon mutation synergizes with fetal alcohol exposure, producing 31 HPE phenotypes closely resembling those seen in humans. We report here that, unexpectedly,
32Nodal, not HH, signaling is the point of synergistic interaction between Cdon mutation and fetal 33 alcohol. Window-of-sensitivity, genetic, and in vitro findings are consistent with a model whereby 34 brief exposure of Cdon mutant embryos to ethanol during gastrulation transiently and partially 35 inhibits Nodal pathway activity, with consequent effects on downstream HH signaling during 36 midline patterning. These results illuminate mechanisms of gene-environment interaction in a 37 multifactorial model of a common birth defect.